Health effects of e-cigarettes, heated tobacco, and oral nicotine products

Vol.:(0123456789)
In e nal and Eme gency Medicine (2025) 20:1671–1673
h ps://doi.o g/10.1007/s11739-025-04057-4
IM - EDITORIAL
Heal h e ec s o e‑ciga e es, hea ed obacco, ando al nico ine
p oduc s
Ricca doPolosa1,2,3 · B adRodu4,5· Kons an inosFa salinos6,7
Recei ed: 3 July 2025 / Accep ed: 6 July 2025 / Published online: 18 July 2025
© The Au ho (s), unde exclusi e licence o Socie à I aliana di Medicina In e na (SIMI) 2025
Ciga e e smoking emains he leading p e en able cause o
disease and p ema u e dea h wo ldwide [1, 2]. T adi ional
obacco con ol e o s ha e ocused p ima ily on p e en ing
ini ia ion and p omo ing cessa ion. While hese app oaches
emain cen al pilla s, many indi iduals con inue o s uggle
wi h long- e m abs inence, o en cycling h ough elapse and
emission [3, 4]. This pe sis en bu den unde sco es he need
o complemen a y s a egies, such as obacco ha m educ-
ion (THR), which is o mally acknowledged in he Wo ld
Heal h O ganiza ion’s F amewo k Con en ion on Tobacco
Con ol [5].
THR is g ounded in he p inciple ha while nico ine
use sus ains dependence, i is he inhala ion o oxican s
p oduced by he combus ion o obacco ha is p ima ily
esponsible o smoking- ela ed diseases such as cance ,
ca dio ascula disease, and espi a o y illness [6, 7]. Nico-
ine i sel , al hough addic i e, is no he chie culp i in he
pa hogenesis o hese condi ions.
By ansi ioning om combus ible ciga e es o non-
combus ible nico ine deli e y sys ems—including elec onic
ciga e es (ECs), hea ed obacco p oduc s (HTPs), and o al
p oduc s such as snus and nico ine pouches—smoke s can
subs an ially educe hei exposu e o ha m ul cons i uen s.
Among hese al e na i es, combus ion- ee p oduc s like
ECs, HTPs, and o al nico ine pouches ha e been consis en ly
shown o emi a ewe oxic subs ances, wi h chemical
exposu e le els anging om ma kedly lowe o negligible
compa ed o adi ional ciga e es.
In a s udy o 181 pa icipan s, exclusi e EC use s showed
a 97% educ ion in NNAL, a ca cinogenic bioma ke , com-
pa ed o ciga e e smoke s. Le els o 1,3-bu adiene and
ac yloni ile—majo obacco- ela ed ca cinogens—we e
also d as ically lowe (11.0% and 2.9%, espec i ely) [8].
These educ ions in ca cinogens we e con i med in he la ge,
na ionally ep esen a i e PATH s udy in ol ing 17,830
adul s [9]. Simila e idence suppo s ha HTPs educed
oxican exposu e compa ed o smoking. In a 12-mon h RCT
wi h 506 smoke s, HTP use s showed ma ked educ ions
in oxican s (e.g., NNAL, 4-ABP, S-PMA), eaching le els
compa able o abs aine s [10]. A second la ge ial (n = 984)
ound simila esul s a e 6mon hs o swi ching o IQOS
[11]. Also, bo h ECs and HTPs elimina e ele a ed exhaled
CO le els, a key ca dio ascula isk ma ke , wi h no maliza-
ion obse ed apidly a e swi ching [12, 13].
Ex ensi e esea ch on snus, a smokeless obacco p od-
uc widely used in Sweden, shows subs an ially educed
exposu e o ha m ul oxican s compa ed o combus ible
ciga e es. Snus use s exhibi signi ican ly lowe le els o
bioma ke s such as NNAL, S-PMA (a benzene bioma ke ),
and 1-HOP (a PAH bioma ke ), o en app oaching he le -
els obse ed in ne e -smoke s [14]. No ably, Swedish men,
who ha e among he highes a es o snus use in Eu ope,
also display some o he lowes obacco- ela ed disease a es,
including lung cance and ca dio ascula disease—suppo -
ing he p oduc ’s ha m educ ion po en ial [15]. Simila ly,
nico ine pouches, which con ain pha maceu ical-g ade nico-
ine bu no obacco lea , o e e en cleane oxicological
p o iles. Independen chemical analyses con i m ha mode n
* Ricca do Polosa
[email p o ec ed]
1 Cen e o Excellence o  heAccele a ion o HA m
Reduc ion (CoEHAR), Uni e si y o Ca ania, Ca ania,, I aly
2 Depa men o Clinical andExpe imen al Medicine,
Uni e si y o Ca ania, Ca ania, I aly
3 Facul y o Medicine andSu ge y, Ko e Uni e si y o Enna,
Enna, I aly
4 James G aham B own Cance Cen e , Uni e si y
o Louis ille, Louis ille, KY, USA
5 Depa men o Medicine, School o Medicine, Uni e si y
o Louis ille, 505 Sou h Hancock S ee , Louis ille,
KY40202, USA
6 Uni e si y o Wes A ica, Agiou Spi idinos, 12243Egaleo,
G eece
7 Uni e si y o Pa as, Panepis emioupoli Pa on, 26504Pa as,
Rio, G eece
1672 In e nal and Eme gency Medicine (2025) 20:1671–1673
pouches con ain ew o no de ec able obacco-speci ic ni os-
amines (TSNAs) o o he combus ion- ela ed oxican s [16].
While long- e m popula ion-le el da a a e s ill limi ed, ea ly
s udies sugges ha nico ine pouches deli e nico ine wi h
minimal exposu e o ha m ul o po en ially ha m ul con-
s i uen s (HPHCs)—compa able o o lowe han hose o
NRT p oduc s (17).
O e he pas 6yea s since i s incep ion, he opical col-
lec ion i led “Heal h Impac o Elec onic Ciga e es and
Hea ed Tobacco Sys ems” has published nea ly 40 pee -
e iewed a icles. The collec ion has accumula ed an agg e-
ga ed Al me ic sco e o close o 3,000, e lec ing s ong
engagemen ac oss bo h academic and public pla o ms. Col-
lec i ely, hese a icles ha e ga ne ed o e 200,000 iews
and downloads and ha e been ci ed nea ly 500 imes, unde -
sco ing he collec ion’s in luence and ele ance in ad ancing
and dissemina ing he scien i ic discou se on no el nico-
ine deli e y p oduc s wi hin he public heal h and clinical
esea ch communi ies.
Building on his success and in esponse o he g owing
in e es in and use o o al nico ine and obacco p oduc s,
he Sp inge edi o ial eam and In e nal and Eme gency
Medicine a e doubling down by elaunching and expanding
he collec ion unde a new i le: “Heal h E ec s o E-Cig-
a e es, Hea ed Tobacco and O al Nico ine P oduc s.”
This expanded ocus e lec s he e ol ing landscape o
nico ine deli e y echnologies, he su ge in consume in e -
es , and he moun ing need o igo ous esea ch on hei
heal h e ec s.
Eme ging da a sugges ha o al nico ine deli e y sys-
ems—including nico ine pouches and Scandina ian snus—
a e addi ional al e na i es ha a e smoke- ee, disc ee , and
less ha m ul han ciga e es. Like ECs and HTPs, hese
p oduc s aise impo an ques ions a ound indi idual isk,
popula ion heal h impac , egula o y amewo ks, and public
pe cep ions. While hey di e in pha macokine ics, senso y
p o iles, and cul u al accep ance, all h ee p oduc ca ego ies
sha e a common ea u e: hey deli e nico ine wi hou com-
bus ion, and hus o e meaning ul ha m educ ion.
We encou age esea che s o submi s udies add essing a
wide spec um o opics, including oxicological p o iles and
compa a i e isk assessmen s, ca dio ascula and espi a-
o y heal h ou comes, bioma ke s udies, he e ec i eness o
hese p oduc s in smoking cessa ion o subs i u ion, pa e ns
o dual and poly-use, as well as public heal h modeling and
egula o y policy implica ions.
We also welcome con ibu ions ha examine he beha io-
al, psychological, and social dimensions o hese p oduc s,
pa icula ly in high- isk o unde se ed popula ions. Submi
you manusc ip he e: h ps:// link. sp in ge . com/ colle c ions/
dbci beagj.
As he landscape o non-combus ible nico ine al e na i es
con inues o e ol e, i is essen ial ha public heal h policy
be guided by igo ous, anspa en , and e idence-based
esea ch. These in es iga ions a e pa icula ly ele an o he
in e nal medicine communi y, as clinicians a e inc easingly
encoun e ing pa ien s who use al e na i e nico ine p od-
uc s and mus na iga e hei ca diopulmona y, me abolic,
and beha io al heal h implica ions ac oss di e se clinical
se ings. By expanding he scope o his opical collec ion,
In e nal and Eme gency Medicine ea i ms i s commi men
o os e ing c i ical discou se and ad ancing bo h clinical
unde s anding and public heal h knowledge in his apidly
de eloping ield.
We encou age in es iga o s, clinicians, and public heal h
schola s o con ibu e o his impo an con e sa ion and
help build a balanced, science-d i en unde s anding o how
elec onic ciga e es, hea ed obacco p oduc s, and o al nico-
ine/ obacco p oduc s impac human heal h.
Da a a ailabili y No applicable.
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