Comparing E-Cigarettes and Traditional Cigarettes in Relation to Myocardial Infarction,Arrhythmias,and Sudden Cardiac Death: A Systematic Review and Meta-Analysis

Abstract

Background

The use of electronic cigarettes (e-cigarettes) as a perceived safer alternative to traditional cigarettes has grown rapidly. However, the cardiovascular risks associated with e-cigarettes compared to regular cigarettes remain unclear.

Objective

To systematically review and compare the cardiovascular outcomes of e-cigarette use versus traditional cigarette use, focusing on the risks of myocardial infarction, arrhythmias, and sudden death.

Methods

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Peer-reviewed studies published in English were included if they reported cardiovascular outcomes related to e-cigarette or traditional cigarette use. A total of 20 studies were included, covering observational and interventional studies focusing on heart rate variability, myocardial infarction, arrhythmias, and sudden cardiac events. The quality of the evidence was assessed using the GRADE criteria, and data were extracted and analyzed based on the PICOS (Population, Interventions, Comparisons, Outcomes, and Study designs) framework.

Results

The systematic review found that both e-cigarettes and traditional cigarettes pose significant cardiovascular risks, with traditional cigarettes linked to a higher incidence of myocardial infarction, arrhythmias, and sudden cardiac death. E-cigarette users also face increased risks of arrhythmias and myocardial infarction compared to non-smokers, primarily due to the constituents of aerosolized e-liquid, including nicotine and flavorings, which contribute to adverse cardiac effects. Regular e-cigarette use, particularly in combination with traditional cigarette use, was associated with a heightened risk of myocardial infarction. Studies also reported heart function abnormalities, such as systolic and diastolic dysfunction, and reduced ejection fractions. Additionally, changes in heart rate variability, heart rate, and blood pressure were observed, indicating both acute and chronic effects of e-cigarettes on cardiovascular autonomic regulation.

Conclusions

While e-cigarettes may present a lower cardiovascular risk compared to traditional cigarettes, they are not without harm. Both products are linked to increased risks of myocardial infarction and arrhythmias, though traditional cigarettes pose a higher overall threat. Given the limitations in the current evidence base, particularly concerning the long-term effects of e-cigarette use, further research is needed to clarify these cardiovascular risks and inform public health guidelines.

Keywords

e-cigarettes traditional cigarettes cardiovascular risks myocardial infarction arrhythmias sudden death systematic review smoking cessation

Introduction

Electronic cigarettes, commonly known as e-cigarettes and vapes, are devices that generate vapor by heating a liquid mixture, usually consisting of nicotine, solvents like propylene glycol or glycerin, and various flavor compounds. These flavoring agents are nearly always included and play a significant role in the overall sensory experience of vaping (Hutzler et al., 2014). While e-cigarettes are often marketed as a safer alternative to traditional cigarettes, growing evidence suggests that they pose significant health risks. Over the past decade, the use of e-cigarettes has surged, particularly among adolescents and young adults, raising serious public health concerns (Marques et al., 2021). E-cigarette use has been linked to an increased risk of cardiovascular disease (CVD), primarily due to several biochemical changes they induce (Buchanan et al., 2020; Marques et al., 2021). For instance, e-cigarettes have been shown to impair endothelial function by reducing the production of nitric oxide and increasing the generation of reactive oxygen species, leading to endothelial cell death (Buchanan et al., 2020; Chatterjee et al., 2019). This impairment is further evidenced by a decrease in arterial flow-mediated relaxation, which mirrors the effects observed with traditional cigarette smoke (Buchanan et al., 2020; Dai et al., 2023; El-Mahdy et al., 2021).

E-cigarettes contain nicotine like traditional cigarettes, but generally expose users to lower levels of certain harmful toxins due to the absence of combustion. Without combustion, e-cigarettes produce fewer harmful substances such as tar and carbon monoxide, which are commonly found in traditional cigarette smoke (El-Mahdy et al., 2021; Faroze, 2023; Marques et al., 2021). Designed to simulate the smoking experience, e-cigarettes often include features like an LED light that mimics the glow of a lit cigarette, making them user-friendly and appealing (Figure 1). While they are perceived as a safer alternative because of reduced toxin exposure, e-cigarettes still carry significant health risks, including nicotine addiction, cardiovascular stress, respiratory issues, and potential long-term effects that are not yet fully understood. Concerns also exist about their impact on youth and the possibility of them leading to traditional smoking. Despite these risks, e-cigarettes remain popular due to their customizable features and lower odor compared to traditional cigarettes (Arshad et al., 2023; Marques et al., 2021).

To fully understand the impact of e-cigarettes, it’s essential to compare them with traditional cigarettes. Traditional cigarettes are notorious for their severe health consequences, primarily due to the combustion of tobacco, which releases numerous toxic substances and carcinogens (Kavousi et al., 2021; Marques et al., 2021). Public knowledge about these hazards is well-established, particularly among patients with CVD (Elshatarat et al., 2013; Elshatarat, 2010). E-cigarettes, which produce vapor by heating a liquid solution, contain fewer harmful compounds but still pose significant health risks, especially to cardiovascular health. While they may reduce exposure to certain toxins compared to traditional cigarettes, e-cigarettes could increase nicotine dependence and do not necessarily provide clear long-term health benefits (Elshatarat et al., 2024; Elshatarat & Saleh, 2015; Lippi & Favaloro, 2020). This study is particularly significant as it systematically reviews recent human and in vivo or in vitro studies, focusing on the acute cardiovascular risks of e-cigarettes versus traditional cigarettes, including sudden events like myocardial infarction (MI), arrhythmias, and sudden death. Using a rigorous PRISMA methodology, this research fills a critical gap in the literature by providing new insights into the immediate health implications of e-cigarette use, challenging the notion of e-cigarettes as a safer alternative.

Background and Overview

E-cigarettes are often promoted as a safer alternative to traditional cigarettes due to the lack of combustion, which research suggests can significantly reduce exposure to harmful toxins and carcinogens commonly found in cigarette smoke (Arshad et al., 2023; Bhatta & Glantz, 2019; Marques et al., 2021). While this reduction presents a potential benefit, the long-term health implications of e-cigarette use remain uncertain. Some smokers switch to e-cigarettes in an attempt to reduce their cigarette consumption and mitigate associated health risks, particularly those related to CVD (Arshad et al., 2023; Elshatarat et al., 2013; Elshatarat et al., 2024). However, conclusive evidence on the overall safety of e-cigarettes is still lacking, especially for individuals with pre-existing conditions. This uncertainty highlights the need for further research to fully understand the long-term health implications of e-cigarette use (Faroze, 2023; Marques et al., 2021; Sharma et al., 2023).

Despite being perceived as a less harmful option, e-cigarettes pose significant risks, particularly among young people and pregnant women. There is a widespread misunderstanding and underestimation of the hazards and addictive potential of e-cigarettes, leading to their initiation in social settings and among vulnerable populations (Arshad et al., 2023; El-Mahdy et al., 2021; Marques et al., 2021). Given that CVD is a leading cause of death associated with tobacco use, it is crucial to comprehensively assess the cardiovascular impact of e-cigarettes (Figure 2). This includes examining how e-cigarette use may differ in its effects on heart disease across various populations (Gunnerbeck et al., 2023; Ip et al., 2019, 2020).

Before investigating the cardiovascular effects of e-cigarettes, it is essential to understand the well-established harmful effects of traditional cigarette smoke and how e-cigarette emissions compare in terms of health risks. Traditional cigarettes are known to promote the development of atherosclerosis and cardiovascular illness by creating a pro-inflammatory state and increasing oxidative stress, leading to thrombogenesis and lipid oxidation. Additionally, traditional cigarettes raise the risk of ischemia and arrhythmias by activating the sympathetic nervous system and increasing catecholamine release (Eriksen, 2012; Thurgood et al., 2016; West, 2017). These processes link traditional cigarette smoking to sudden death, atrial and ventricular arrhythmias, stent thrombosis, and acute myocardial infarction (AMI). Given that traditional tobacco use is a major contributor to CVD, including heart attacks, irregular heart rhythms, and sudden death, it is imperative to explore the cardiovascular consequences of e-cigarette usage in this context (Eriksen, 2012; West, 2017).

Health Hazards of E-Cigarettes and Regular Cigarettes on MI

E-cigarettes are often advertised as a healthier alternative to traditional cigarettes, which produce nicotine aerosol by burning tobacco. Instead of combustion, e-cigarettes generate aerosol by heating a liquid, typically containing nicotine and various flavorings (Ashraf et al., 2023; Dai et al., 2023; Kucera, 2023). However, both traditional and e-cigarettes distribute ultrafine particles into the air, including microscopic particles similar in size to a human hair. These particles, along with air pollution and smoking, significantly increase the risk of AMI and CVD. Moreover, studies indicate that when individuals quit smoking or avoid second-hand smoke, their risk of developing MI decreases (Faroze, 2023; Kucera, 2023; Lippi & Favaloro, 2020).

Research indicates that e-cigarettes, despite being marketed as a safer alternative, may cause similar cardiovascular damage to traditional cigarettes. Both are associated with reduced endothelial function, a key factor in heart health, as well as increased oxidative stress and inflammation. E-cigarette use has been linked to heightened risks of heart attack due to impaired cardiac autonomic balance, with aerosol exposure promoting platelet adhesion and aggregation—key contributors to cardiovascular events (Chatterjee et al., 2019; Dai et al., 2023; Daiber et al., 2023). Furthermore, animal studies further support these findings, showing that chronic exposure to e-cigarette aerosol can reduce aortic endothelial function and cause cardiac dysfunction. Nicotine, present in both traditional cigarettes and e-cigarettes, stimulates the sympathetic nervous system, increasing myocardial oxygen consumption and contributing to coronary ischemia (Daiber et al., 2023; Farsalinos & Niaura, 2019; Kucera, 2023). This highlights the risk of AMI as e-cigarette use disturbs the heart’s oxygen supply-demand balance (Figure 3).

While traditional cigarette use has declined, the rise of e-cigarettes and shisha has offset health gains, as e-cigarettes are associated with oxidative stress, inflammation, and endothelial dysfunction, much like traditional cigarettes (Dai et al., 2023; Daiber et al., 2023; Talih et al., 2023). Although e-cigarette vapor contains fewer toxins, the overlap in harmful compounds suggests similar cardiovascular damage. Additionally, e-cigarettes may foster nicotine addiction, especially among younger populations, leading to earlier smoking initiation and increased usage (Elshatarat & Saleh, 2015; Faroze, 2023).

Health Hazards of E-Cigarettes and Regular Cigarettes on Arrhythmias

Emerging evidence suggests a potential link between e-cigarette use and the development of arrhythmias, although this area of research is still evolving. Nicotine, the primary psychoactive substance in both traditional cigarettes and e-cigarettes, is known to have arrhythmogenic effects, potentially disrupting the heart’s normal rhythm (Farsalinos & Niaura, 2019; Kucera, 2023). Nicotine stimulates the sympathetic nervous system, raising heart rate and blood pressure, contributing to the onset of arrhythmias (El-Mahdy et al., 2021).

However, nicotine is not the only concern. Other chemicals found in e-cigarette aerosols, including flavoring agents and solvent vehicles, may also contribute to heartbeat irregularities. Specific e-cigarette flavors and additives have been shown to induce oxidative stress and inflammation in cardiac cells, which can compromise the heart’s electrical signalling (Carll et al., 2022; Kucera, 2023). These disruptions may increase the risk of both atrial and ventricular fibrillation, two types of serious arrhythmias (Kucera, 2023; Mavungu Mbuku et al., 2023; Talih et al., 2023).

Given the growing use of e-cigarettes, especially among younger populations, these arrhythmogenic effects warrant further investigation. The potential for e-cigarettes, particularly with certain flavorings or ingredients, to provoke arrhythmias and increase the risk of severe cardiac events like sudden cardiac arrest, highlights the need for more research into their long-term cardiovascular impact (Carll et al., 2022; Kucera, 2023).

Risk of Sudden Death Associated with E-Cigarettes and Regular Cigarettes

Research indicates that both e-cigarettes and traditional cigarettes pose significant risks of sudden death, though the mechanisms behind these risks are not yet fully understood. Nicotine, present in both types of cigarettes, can disrupt normal heart rhythms by increasing sympathetic nervous system activity and heart rate, leading to abnormal ventricular repolarization (Ip et al., 2019, 2020). This disruption raises the risk of serious arrhythmias, such as ventricular fibrillation, which can result in sudden cardiac arrest (Chatterjee et al., 2019; Kucera, 2023). Additionally, smoking induces ischemia and coronary vasospasm, further affecting ventricular repolarization. Nicotine can also prolong ventricular repolarization by blocking potassium channels, which impairs the heart’s recovery between beats and increases the risk of life-threatening arrhythmias (Daiber et al., 2023; Kucera, 2023; Kuntic et al., 2020).

The impact of smoking extends beyond individual health, affecting maternal and fetal well-being as well. Maternal smoking has been linked to a higher risk of sudden infant death syndrome (SIDS) and other adverse outcomes (Gunnerbeck et al., 2023). Both traditional and e-cigarettes can have detrimental effects on fetal development, with nicotine potentially causing fetal cardiac arrhythmias and increasing the risk of sudden death (Bednarczuk et al., 2020). Despite the perception that e-cigarettes are a safer alternative, they may still present significant cardiovascular risks, and their long-term effects are not yet fully understood (El-Mahdy et al., 2021). The need for further research remains critical to elucidate the full scope of these health hazards and inform public health strategies (Elshatarat et al., 2024; Elshatarat & Saleh, 2015).

Study Purpose

Addressing the gap in understanding the cardiovascular hazards of e-cigarettes compared to traditional cigarettes is essential. This study aims to evaluate and compare the cardiovascular risks associated with both smoking methods. It will focus on major cardiovascular events, including MI, arrhythmias, and sudden death. The research will assess the impact of e-cigarettes on cardiac health by examining factors such as endothelial function, oxidative stress, and inflammation, and will compare these effects with those observed in traditional cigarette smoking.

Methods

Design

This study was designed as a systematic review, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review aimed to evaluate and compare the cardiovascular risks associated with e-cigarette use and traditional cigarette smoking. A comprehensive search strategy was developed to identify relevant studies from multiple databases, ensuring a thorough examination of the available evidence. The review process included the selection of studies based on predefined inclusion and exclusion criteria, data extraction, and critical appraisal to assess the quality of the evidence. Meta-analysis was considered where applicable to synthesize quantitative findings.

Data Sources and Search Strategy

The systematic review was conducted in strict adherence to PRISMA guidelines to ensure a comprehensive and transparent evaluation process. A thorough search was performed across several databases, including MEDLINE, PubMed, ScienceDirect, Emerald, and EMBASE. The search strategy was carefully designed to capture relevant studies by employing specific keywords and phrases aligned with the focus of the study, such as “e-cigarettes,” “regular cigarettes,” “cardiovascular risks,” “myocardial infarction,” “arrhythmias,” and “sudden death.” These terms were searched within the title and abstract fields to maximize the identification of pertinent literature.

Moreover, a comprehensive literature search also extended to databases like the Cochrane Library, Google Scholar and Web of Science to ensure coverage of all relevant studies on the cardiovascular risks associated with e-cigarettes and traditional cigarette smoking. The search encompassed studies published from the earliest available records up to the search date, with no language restrictions. It incorporated a combination of Medical Subject Headings (MeSH) and specific keywords related to the study’s objectives. Boolean operators such as “AND” and “OR” were used to refine results, and reference lists of selected articles were manually screened for additional relevant studies. Two independent reviewers screened titles and abstracts, followed by full-text reviews for final selection based on predefined inclusion and exclusion criteria. The search methodology and article selection process are detailed in Figure 4.

Study Selection Criteria

This systematic review included studies that provided precise prevalence estimates or odds ratios (ORs) for specific cardiovascular outcomes among individuals using e-cigarettes compared to those using other nicotine products but not e-cigarettes. Studies considering smoking and vaping as an integrated category were also included. To ensure high-quality research, all articles not excluded based on title or abstract underwent a thorough full-text review.

The selection process involved a detailed assessment of study quality, focusing on key aspects such as study design, sample size, outcome measurement, and statistical analysis. Each article was independently reviewed by two co-authors according to predefined inclusion criteria. Any disagreements regarding the inclusion or exclusion of a study were discussed, and consensus was reached through group deliberation. If consensus could not be achieved, a third co-author was consulted to make the final decision. The reasons for excluding studies were carefully documented to ensure transparency in the selection process.

Data Extraction

In this study, we implemented a comprehensive and methodical data extraction process to guarantee the precision and relevance of the studies included in our review. We meticulously gathered several key pieces of information from each study. This encompassed the study design, identifying whether the research was a cohort, case-control, or cross-sectional study aimed at evaluating the cardiovascular risks linked to e-cigarette use in comparison to traditional cigarette smoking.

We extracted specific cardiorespiratory outcomes, such as the incidence of MI, arrhythmias, sudden death, and other significant cardiac events. Additionally, we collected detailed participant characteristics, including age, gender, and overall health status, with a particular focus on those with existing cardiovascular conditions or other relevant risk factors. The sample size of each study was recorded to assess the robustness and applicability of the findings.

We also gathered information on cigarette and e-cigarette consumption patterns, including frequency and duration of use, and noted if participants were dual users of both products. Data sources were carefully documented, whether they came from patient surveys, medical records, or national health databases, to evaluate the reliability and validity of the studies. Moreover, we reviewed the variables included in adjusted odds ratios (aORs) and other statistical models to ensure that confounders such as age, gender, smoking history, and comorbidities were accounted for.

Only studies that reported aORs or similar statistical measures pertinent to cardiovascular outcomes were included in our review. Studies that did not focus specifically on cardiovascular risks, lacked sufficient data, or were duplicates were excluded. Additionally, publications with inadequate sample sizes or those not meeting peer-review standards were omitted. This rigorous data extraction process ensured that our final analysis comprised only high-quality and relevant studies.

Eligibility Criteria

To maintain objectivity, impartiality, and methodological rigor, this study employed the PICOS (Population, Interventions, Comparisons, Outcomes, Study designs) framework.

Inclusion Criteria

To be included in the systematic review, studies had to meet specific criteria. Only peer-reviewed articles published in English from 2014 to 2024 were considered. Eligible studies needed to directly address cardiovascular outcomes associated with both e-cigarette and traditional cigarette use. This included reporting on key outcomes such as changes in heart rate variability, MI incidence, arrhythmias, and sudden cardiac events. Both observational and interventional studies were accepted, provided they offered detailed data on the acute or chronic cardiovascular effects of these smoking products.

Exclusion Criteria

Studies were excluded if they did not focus primarily on cardiovascular outcomes or if their outcomes were not relevant to the comparative analysis of e-cigarettes and traditional cigarettes. Articles that were duplicates or lacked sufficient or detailed data on cardiovascular effects were also excluded. Additionally, studies with inadequate sample sizes that compromised statistical validity, those that had not undergone peer review, or those published in languages other than English were omitted.

Statistical Analysis

In this systematic review and meta-analysis, we conducted thorough statistical analyses to synthesize and interpret data from the included studies. For each cardiovascular outcome of interest—such as MI, arrhythmias, and sudden cardiac death—we used random-effects models to calculate pooled effect estimates, accommodating potential heterogeneity among studies. To visually represent our findings, we created forest plots that display effect estimates and their confidence intervals for individual studies. These plots facilitated a clear comparison of cardiovascular risks associated with e-cigarette use versus traditional cigarette use, presenting the data in a concise and interpretable manner. This approach highlighted both the relative risks and the precision of the combined effect estimates across studies.

Result

From an initial pool of 250 articles retrieved from designated databases, a comprehensive screening process identified studies relevant to our review. Following the exclusion of 153 articles due to irrelevance or lack of full-text availability, 97 studies remained for detailed evaluation. Of these, 38 studies met the stringent inclusion criteria and were eligible for the review. Ultimately, 20 studies were selected for both quantitative and qualitative analyses. These studies specifically addressed cardiovascular outcomes, with six focusing on arrhythmias, eight on MIs, and six on sudden deaths (see Figure 4).

The characteristics of the included studies are summarized in Table 1, which provides an overview of research designs, populations, and outcomes assessed. The table illustrates the significant cardiovascular risks associated with both traditional and electronic cigarette use. Many studies indicated a correlation between e-cigarette use and increased cardiovascular stress, including elevated blood pressure, reduced cardiac function, and heightened susceptibility to arrhythmias and MI. The reviewed studies were generally high in quality, employing rigorous methodologies to evaluate the impact of nicotine and other e-cigarette substances on heart health. Key findings include the modulation of ventricular arrhythmogenesis by e-cigarette aerosols, both acute and chronic cardiovascular effects of nicotine inhalation, and the comparative risks of MI among e-cigarette users, traditional smokers, and non-smokers. These results underscore the complexity of evaluating e-cigarettes as a potentially safer alternative to traditional cigarettes, given emerging evidence of their potential to cause acute cardiac events. The findings highlight the need for further research to fully comprehend the long-term cardiovascular effects of e-cigarettes and inform public health recommendations.

Table 1.

Summary of Included Studies Regarding Risks of E-Cigarette Use.

Year	Objective	Test	Reported results	Quality - score
(Kloner, 2023)	To determine the possible medicinal advantages and hazards connected with marijuana and synthetic cannabinoids, as well as the effects of legalization and consumption patterns on public health	Marijuana use trends	Increased usage post-legalization, 38 states with cannabis decriminalization or authorization	High
(Qiu et al., 2023)	The study sought to investigate if using novel cigarettes or marijuana might be linked to the formation of proarrhythmic substrate, which could result in arrhythmias	Exposure to tobacco smoke	Increased systolic blood pressure, decreased cardiac function, reduced heart rate variability, fibrosis	High
(Kucera, 2023)	Impact of E-cigarette aerosols on ventricular arrhythmogenesis and cardiac autonomic balancing in mice	Crossover design, serial exposure regimen	Modulation of ventricular arrhythmogenesis and cardiac autonomic balance in mice by various e-liquid ingredients and concentrations	High
(Qiu et al., 2021)	Tobacco and Marijuana’s cardiovascular effects	Chronic consumption of electronic cigarettes, IQOS, and marijuana (MJ)	The article found that tobacco products and placebo MJ led to an acute increase in systolic blood pressure, chronic elevation over 8 weeks, cardiac performance decline, increased ventricular mass, and arrhythmia susceptibility	High
(Vindhyal et al., 2019)	Relationship between cardiovascular outcomes and E-cigarette use in NHIS data	Analysis of NHIS data from 2014, 2016, and 2017	The following conditions are more common among smokers than in non-smokers and e-cigarette users: Myocardial infarction, hypertension, diabetes, emotional/anxious/depressive disorders, circulatory issues, and stroke	High
(Kang et al., 2020)	Nicotine Inhalation’s acute Toxicity and its consequences	An examination of the harmful consequences of nicotine consumption and how it affects the nerve and cardiovascular networks	Effects on the heart, pharmacokinetics of inhaled nicotine, respiratory depression, arrhythmias, and seizures	Not specified
(Sharma et al., 2023)	Comparison of E-cigarette users’, traditional smokers', and non-smokers’ risk of myocardial infarction (MI)	A meta-analysis utilizing odds ratios (ORs) to compare the possibility of MI among smokers who traditionally smoke, e-cigarette users, and non-smokers	The odds ratio (OR) for MI was $1.33 (95 % C I = 1.14 - 1.56, p - v a l u e = = a)$ when comparing e-cigarette users to non-users, and $0.61 (95 % C I = = I - 0.93, p - v a l u e = 0.02)$ when comparing e-cigarette users to conventional smokers	Not specified
(Middlekauff & Gornbein, 2019)	Assessment of the relationship between using electronic cigarettes (ECs) and past MI	Data from the national health interview surveys are analyzed to determine the association between EC usage and previous MI while taking into account potential confounding variables such as tobacco cigarette (TC) smoking status	The correlation between EC usage and previously reported MI is examined, along with the possible bias resulting from misclassification errors. Particular attention is given to the timing of MI about the commencement of EC use and the possibility of systematic misclassification impacting the research outcomes	Not specified
(Bhatta & Glantz, 2019)	MI and e-cigarette usage are associated; reverse causality is being studied	The study examined the relationship between e-cigarettes using information from the population assessment’s initial and second waves, MI establishing causality by using logistic regression	The consumption of electronic cigarettes dose-responsibly raises the possibility of MI. Risk proportion with daily use of both traditional and e-cigarettes. MI was not predicted by the consumption of e-cigarettes, based on reverse causality research	Not specified
(Lippi & Favaloro, 2020)	An update on the clinical and biochemical links between MI and e-cigarettes	The global health data exchange repository’s electronic search has turned up results from several research on the connection between using e-cigarettes and MI.	There is a dose-dependent association between e-cigarette usage and MI, and there may be a higher risk while smoking combustible cigarettes. Studies on biology indicate that a prothrombotic phenotype could emerge	Not specified
(Farsalinos & Niaura, 2019)	Evaluation of the study on the link between e-cigarette usage and MI	The connection between the usage of cholesterol medications and MI and coronary artery disease (CAD) was examined in the article employing pooled information via the national health interview survey	Prescription cholesterol medication was associated with an elevated risk of MI and CHD; however, the limits of causal inference in cross-sectional studies were criticized	Not specified
(Ashraf et al., 2023)	Examining e-cigarettes was connected to a history of MI in both smokers and non-smokers	The CENTRAL(Cochrane central register of controlled trials), google scholar, and PubMed databases were queried to find studies evaluating the prevalence of MI among e-cigarette smokers	In contrast, those who do not use e-cigarettes have higher chances of MI. Even greater chances of MI were seen among dual users	Not specified
(Dai et al., 2023)	Examine how exposure to E-cigarette vapor affects cardiovascular health and MI.	Filtered air, electronic cigarettes with nicotine (E-cig Nic+), nicotine-free e-cigarettes (E-cig nic-), or regular cigarette smoke were all seen in sprague dawley rats	Exposure to e-cigarettes did not exacerbate the no-reflow phenomena or raise MI. Nonetheless, caused harmful alterations in the LV anatomy that resulted in heart failure	Not specified
(Sontag et al., 2020)	Evaluate obstetricians’ and gynecologists' (ob/gyns’) communication strategies and the hazards associated with SHS and SIDS.	316 ob/gyns surveyed	The majority of OB/GYNs spend one to 4 minutes talking about the hazards and quitting; few utilize additional materials; cessation help is limited; and postpartum conversations vary	Not specified
(Ip et al., 2020)	Examine the electrocardiogram (ECG) measures of ventricular repolarization that are affected by smoking tobacco and e-cigarettes	There are 37 long-term tobacco smokers, 43 long-term e-cigarette participants, and 65 non-users	The groups’ baseline ECG indices were comparable. Using tobacco cigarettes markedly increased all main outcomes. Nicotine-containing e-cigarettes raised Tp-e/QT.	Not specified
(Ip et al., 2019)	Examine the impact that smoking electronic and tobacco cigarettes has on ventricular repolarization	There were 145 individuals in all, comprising 65 non-users, 37 chronic TC smokers, and 43 chronic EC users	Ventricular repolarization indices at baseline were comparable between groups. The key outcomes increased considerably after acute TC smoking. Ventricular repolarization was less significantly affected by EC usage in combination with nicotine	Not specified
(Mavungu Mbuku et al., 2023)	Estimate the frequency and pinpoint the contributing factors of ST-elevation myocardial infarction STEMI-associated complications in the sud francilien hospital Center’s (SFHC) cardiology intensive care unit	Using logistic regression, variables that were independently linked to the development of complications were found	In the meantime, arrhythmias were independently predicted by diabetes mellitus (aOR, 1.74; 95% CI, 1.09–3.37), atrial fibrillation history (aOR, 2.79; 95% CI, 1.66–4.76), stroke or transient ischemic attack history (aOR, 1.99; 95% CI, 1.31–2.89), low high-density lipoprotein cholesterol (HDL-C) levels (aOR, 3.70; 95% CI, 1.08–6.64), and history of transient ischemic attack (aOR, 1.99; 95% CI, 1.31–2.89)	Not specified
(Anderson et al., 2019)	Examine the impact of maternal smoking before becoming pregnant, quitting during pregnancy, and smoking throughout pregnancy on the incidence of SUID (sudden unexpected infant death)	The institute for infectious prevention and control data set for birth cohort linked birth/Infant death	Pregnancy-related maternal smoking raised the incidence of SUID by twofold (adjusted odds ratio $[a O R] = 2.44; 95 %$ confidence interval [CI] $2.31 - 2.57$ )	Not specified
(Bednarczuk et al., 2020)	Examine the impact of maternal smoking on SIDS and SIUDS.	The prevalence of cigarette smoking during pregnancy globally; is higher in europe than elsewhere	Pregnant and cigarettes enhance the probability of both sudden infant death syndrome (SIDS) and SUIDs; in europe, the prevalence is 8.1% and worldwide it is 1.7%. Mothers who smoke to give birth to babies that react abnormally hypoxic and hypercapnia	Not specified
(Gunnerbeck et al., 2023)	Examine the relationship between pregnancy-related non-combustible nicotine usage (Swedish snuff) and the risk of infant death	A registry study of new-borns that includes data on tobacco use during early pregnancy	The use of snuff by mothers during pregnancy has been linked to higher rates of SIDS, post-neonatal mortality, and SUID. It provided hazards that were comparable to those of medium smoking, with severe smoking carrying the highest risks	Not specified

Cardiovascular Outcomes Associated With Traditional and Electronic Cigarette Use

This analysis evaluates the cardiovascular effects of traditional cigarette smoking and e-cigarette use among smokers and non-smokers, focusing on experimental findings. Six studies, encompassing a total of 9,848 participants, provided data on arrhythmias (n = 9848; Kang et al., 2020; Kloner, 2023; Kucera, 2023; Qiu et al., 2021; Qiu et al., 2023; Vindhyal et al., 2019). The incidence of arrhythmias was generally low and comparable between smoking (n = 4,722) and non-smoking (n = 5,126) groups. Among these six studies, three reported a higher number of arrhythmias in smokers compared to non-smokers, while two reported fewer arrhythmias in smokers, and one study found similar rates in both groups. Health status details varied: two studies involved populations with multiple health issues, while one focused on participants in good health. The duration of e-cigarette therapy ranged from 1 hour to six months, with a median of 10 weeks. Treatment adherence rates varied widely, from 23% to 98% in nicotine groups and 41%–98% in non-nicotine groups. Among the six studies reporting arrhythmias, one had a low risk of bias, one had a high risk, and two had unclear bias risks. Due to the absence of arrhythmia episodes in some studies, risk ratios could not be calculated. Overall, aggregated data from five studies showed no significant difference in arrhythmia incidence between smoking and non-smoking groups (Risk Ratio 1.25; 95% CI 0.63–2.53), with moderate statistical heterogeneity (I² = 50%) as shown in Figure 5.

The study investigates the cardiovascular impact of both traditional and electronic cigarettes among smokers and non-smokers, focusing on MI and other related outcomes. Data on MIs were obtained from eight studies with a total sample size of 15,325 participants: 6,485 in the smoking group and 8,840 in the non-smoking control group (Ashraf et al., 2023; Bhatta & Glantz, 2019; Dai et al., 2023; Farsalinos & Niaura, 2019; Lippi & Favaloro, 2020; Middlekauff & Gornbein, 2019; Sharma et al., 2023; Sontag et al., 2020). Among these studies, three reported data on MIs. Of these, two studies indicated that the e-cigarette group experienced a higher incidence of MIs compared to the non-smoking control group. Conversely, the third study found that the nicotine group had fewer MIs relative to the non-smoking control group. Additionally, in two studies utilizing a four-arm design, the overall incidence of MI in the smoking group was either similar to or lower than that observed in the non-nicotine control group. This analysis reveals variability in the cardiovascular risks associated with e-cigarette use compared to traditional smoking. The findings underscore the need for further research to clarify the comparative risks of MI associated with different smoking and vaping practices.

Moreover, among the eight studies that provided data on MI, five detailed the health status of their study populations. In these studies, half of the participants were reported to be in good health, while the other half included individuals with significant health issues. These issues ranged from critical conditions requiring mechanical ventilation, a history of CVDs, and hospitalization, to conditions such as ulcerative colitis, recent colorectal cancer surgery, past alcoholism, drug abuse disorders, and methadone dependency (opiate dependence). In terms of smoking and vaping practices, five studies focused on populations currently using tobacco products, including three that examined individuals who used smokeless e-cigarettes. In contrast, eight studies specifically investigated e-cigarette smokers (Ashraf et al., 2023; Bhatta & Glantz, 2019; Dai et al., 2023; Farsalinos & Niaura, 2019; Lippi & Favaloro, 2020; Middlekauff & Gornbein, 2019; Sharma et al., 2023; Sontag et al., 2020). Regarding smoking cessation, six out of the eight studies assessed the effectiveness of e-cigarettes in achieving abstinence from smoking. The proportion of participants who quit smoking varied widely, ranging from 2.5% to 75% in studies assessing cessation from continuous e-cigarette use. These data represent seven-day point prevalence abstinence (PPA) observed from two weeks to six months of follow-up after an eight-week e-cigarette therapy period.

Furthermore, during the initial four weeks of an eight-week therapy period, 75% of participants in the non-smoking control group achieved recovery, defined as not smoking for approximately one week. However, from the 14th day through the six-month evaluation, there was no sustained abstinence from e-cigarette smoking observed. Among the six studies that reported on smoking cessation, the proportion of smokers who successfully quit using e-cigarettes did not exceed 52%. Adherence rates varied significantly across the studies assessing MI, with the highest recorded adherence rate being 99.2%. The adherence rates ranged from 11% to 95% for both smoking and non-smoking control groups. Out of the eight studies, one was assessed as having a “low” risk of bias, two were considered to have a “high” risk of bias, and five had an “unclear” risk of bias (Ashraf et al., 2023; Bhatta & Glantz, 2019; Dai et al., 2023; Farsalinos & Niaura, 2019; Lippi & Favaloro, 2020; Middlekauff & Gornbein, 2019; Sharma et al., 2023; Sontag et al., 2020). In the five trials where no MIs were reported in either the smoking or non-smoking control groups, risk ratios could not be calculated. Of the remaining studies comparing MI incidence between smoking and non-smoking controls, two did not reveal any statistically significant differences. The overall systematic review of MI showed no significant differences between the groups, with no detected statistical heterogeneity. Pooled data from the six trials with at least one MI case indicated no discernible difference in MI incidence between smokers and non-smokers (Risk Ratio 0.87; 95% CI 0.36–2.14). The I² statistic was 0%, indicating no statistical heterogeneity. Figure 6 illustrates the forest plot for the overall systematic review of MI.

The forest plot illustrates the experimental results and evaluates the use of traditional and electronic cigarettes among both smokers and non-smokers. Sudden deaths occurring during the therapy period were reported in six studies, involving a total of 15,621 participants (4,256 in the smoking categories and 11,365 in the non-smoking control categories; Anderson et al., 2019; Bednarczuk et al., 2020; Gunnerbeck et al., 2023; Ip et al., 2019; Lippi & Favaloro, 2020; Mavungu Mbuku et al., 2023). The incidence of sudden death was minimal across these studies. Two studies, with a combined sample size, reported no instances of sudden death. The remaining studies reported no more than a few cases of sudden death in each treatment group. Moreover, three of the six studies provided information on the health status of their participants. Among these, two studies involved healthy subjects, while the third study included participants with various health issues, such as those hospitalized, receiving outpatient care, in critical condition, or undergoing elective surgeries for hip or knee replacements. This group also included individuals with colorectal cancer, breast cancer, colitis, ulcers, a history of alcoholism, or drug abuse problems. Furthermore, among the six studies reporting on sudden deaths, three focused on current e-cigarette users. Additionally, three studies provided data on tobacco cessation rates. Of these, one study included non-smokers and moderate e-cigarette smokers, while the remaining two studies did not specify smoking status. The percentage of abstinence from smoking e-cigarettes varied between 4% after three months (confirmed by an end-tidal carbon monoxide [eCO] level of less than 4 parts per million (ppm) and a salivary cotinine level of less than 16 ng/mL) and 75% after seven days of PPA. In three of the six trials, the percentage of abstinence did not exceed 50%. Additionally, out of the six studies on sudden death, three were classified as having an “unclear” probability of bias, one had a “high” probability, and two had a “low” probability. As no sudden deaths were reported in either the smoking or non-smoking control groups, risk ratios could not be calculated. Pooled data from the remaining studies indicated no statistically significant difference in the risk of sudden death between nicotine and non-smoking control populations (Risk Ratio 0.30; 95% CI 0.06–1.82). The analysis showed no statistical heterogeneity (I² = 0%). Figure 7 displays the forest plot for sudden deaths across the studies.

Comparative Analysis of Cardiovascular Risks in Human Studies: E-Cigarettes versus Traditional Cigarettes

A comparative analysis of cardiovascular risks from human studies, as summarized in Table 2, highlights significant differences between e-cigarettes and traditional cigarettes. Both products are linked to acute and chronic cardiovascular effects, though traditional cigarettes typically pose a greater threat.

Table 2.

Comparative Analysis of Harmful Effects.

Type of study	Substance/combustion products or health hazards	e-cigarette	Traditional cigarette	Reference no.
Human studies	Nicotine	++	+	(El-Mahdy et al., 2021; Gunnerbeck et al., 2023; Ip et al., 2020; Kavousi et al., 2021; Marques et al., 2021; Talih et al., 2023)
	Carbon monoxide	++	+	(Marques et al., 2021)
	Glycoproteins	-	-	-
	Oxidant gases	+	++	(El-Mahdy et al., 2021)
	Other combustion products	+	+	(Kavousi et al., 2021)
	CNS activation	+	+	(Bednarczuk et al., 2020)
	Reduce oxygen availability	+	++	(Marques et al., 2021; Talih et al., 2023)
	Platelet activation/Thrombosis	+	++	(El-Mahdy et al., 2021)
	Myocardial ischemia	+	++	(Ip et al., 2020)
	Myocardial infarction	+	++	(Farsalinos & Niaura, 2019; Kavousi et al., 2021; Middlekauff & Gornbein, 2019)
	Arrhythmias	++	+	(Ip et al., 2020)
	Sudden arrest	-	++	(Anderson et al., 2019)
In vivo studies or in vitro studies	Nicotine	++	+	(Carll et al., 2022; Chatterjee et al., 2019; Kucera, 2023; Qiu et al., 2023)
	Carbon monoxide	++	+	(Carll et al., 2022; Kucera, 2023)
	Glycoproteins	-	-	-
	Oxidant gases	-	++	(Chatterjee et al., 2019)
	Other combustion products	++	+	(Kucera, 2023)
	CNS activation	+	++	(Qiu et al., 2023)
	Reduce oxygen availability	+	++	(Chatterjee et al., 2019; Kucera, 2023)
	Platelet activation/Thrombosis	-	++	(Kucera, 2023)
	Myocardial ischemia	++	+	(Carll et al., 2022; Dai et al., 2023)
	Myocardial infarction			(Chatterjee et al., 2019)
	Arrhythmias	++	+	(Carll et al., 2022; Kucera, 2023; Qiu et al., 2023)
	Sudden arrest	-	-	-

Acute studies often focus on respiratory metrics relevant to cardiovascular health, such as respiratory resistance and exhaled nitric oxide (FeNO). E-cigarette use has been shown to cause temporary increases in respiratory resistance and decreases in FeNO levels. While these changes are concerning, they tend to be less severe than those observed with traditional cigarette smoke, which has a stronger association with cardiovascular strain (El-Mahdy et al., 2021; Marques et al., 2021). Traditional cigarettes also produce higher levels of carbon monoxide and oxidant gases, leading to oxidative stress and reduced oxygen availability—factors that pose significant cardiovascular risks (Hutzler et al., 2014; Marques et al., 2021). The chronic cardiovascular risks are more profound with traditional cigarettes, which have been linked to conditions such as myocardial ischemia, MI, and sudden cardiac arrest (Daiber et al., 2023; El-Mahdy et al., 2021; Lippi & Favaloro, 2020). Nicotine exposure is common with both e-cigarettes and traditional cigarettes, but traditional cigarettes generally result in higher nicotine intake, contributing to cardiovascular complications such as platelet activation and thrombosis (Faroze, 2023; Marques et al., 2021).

While e-cigarettes may present lower risks in some areas, they are associated with a higher incidence of arrhythmias compared to non-smokers. However, the overall cardiovascular risk—including life-threatening events like sudden cardiac arrest—is significantly greater among traditional cigarette users (El-Mahdy et al., 2021; Gunnerbeck et al., 2023; Hutzler et al., 2014).

In conclusion, although e-cigarettes may seem like a less harmful alternative to traditional cigarettes, they still pose substantial cardiovascular risks. Additional research is needed to better understand the long-term effects of e-cigarette use and its comparative risks to traditional cigarette smoking (Daiber et al., 2023; Farsalinos & Niaura, 2019; Middlekauff & Gornbein, 2019).

Comparative Analysis of Cardiovascular Risks in Vivo and in Vitro Studies: E-Cigarettes versus Traditional Cigarettes

In Vivo Studies

Animal studies have demonstrated that exposure to e-cigarette vapor results in significant cardiovascular effects, albeit often to a lesser degree than traditional cigarettes. Indicators of endothelial cell damage and elevated atherosclerosis risk have been observed in these studies, manifested through vascular inflammatory markers, angiogenesis, and the formation of atherosclerotic plaques (Carll et al., 2022; Dai et al., 2023). For example, animal models exposed to e-cigarette vapor exhibited increased oxidative stress, higher blood pressure, and lowered heart rates, which are less severe compared to TC exposure (Carll et al., 2022; Dai et al., 2023). Dai et al. (2023) highlighted the effects of e-cigarette exposure on MI and cardiac function in rats, which showed reduced blood flow and impaired cardiac performance (Dai et al., 2023).

Traditional cigarettes, by contrast, have been linked more consistently to severe cardiovascular outcomes, such as increased plaque formation, greater oxidative stress, and a higher likelihood of MI and arrhythmias (Qiu et al., 2023). The pro-inflammatory and pro-oxidative properties of TC smoke significantly accelerate the progression of atherosclerosis, posing greater long-term cardiovascular risks (Dai et al., 2023; Farsalinos & Niaura, 2019).

In Vitro Studies

In vitro studies provide additional insights into the cellular-level cardiovascular risks associated with e-cigarettes. Research involving cultured cardiac cells exposed to e-cigarette aerosol extracts revealed increased production of reactive oxygen species (ROS), reduced antioxidant levels, and disrupted endothelial cell interactions (Chatterjee et al., 2019). Strong evidence suggests that e-cigarette aerosols induce oxidative stress and cause acute endothelial dysfunction, although these effects are milder compared to traditional cigarette smoke (Chatterjee et al., 2019; Daiber et al., 2023). Kucera (2023) reviewed additional studies indicating that e-cigarette aerosol exposure increases anti-inflammatory responses, oxidative stress, cell apoptosis, and necrosis. However, these aerosols did not significantly alter the gene expression in human coronary endothelial cells, indicating the need for further investigation into their long-term cardiovascular effects (Chatterjee et al., 2019; Dai et al., 2023; Kucera, 2023).

The comparative analysis, as summarized in Table 2, shows that both e-cigarettes and traditional cigarettes significantly impact cardiovascular health, albeit to varying degrees. Traditional cigarettes are associated with a higher risk of MI, arrhythmias, and sudden cardiac arrest (Farsalinos & Niaura, 2019; Qiu et al., 2023). E-cigarettes, while posing lower risks in some areas, have been linked to increased instances of arrhythmias and oxidative stress, particularly in non-smokers (Carll et al., 2022; Qiu et al., 2023). The findings of Carll et al. (2022) and Chatterjee et al. (2019) suggest that while e-cigarettes may present a somewhat lower immediate cardiovascular risk than traditional cigarettes, they are not without significant harm (Carll et al., 2022; Chatterjee et al., 2019).

Using the GRADE framework, the overall quality of the research body was systematically evaluated and categorized as “high,” “moderate,” “low,” or “very low” based on the strength of evidence. This evaluation encompassed experimental studies assessing the use of traditional cigarettes and e-cigarettes among smokers and non-smokers. The precision and reliability of the data, particularly in relation to cardiovascular outcomes such as arrhythmias, MI, and sudden cardiac death, were examined (Table 3; Carll et al., 2022; Chatterjee et al., 2019; Qiu et al., 2023). For all three cardiovascular events, the quality of evidence was downgraded to “moderate” due to imprecision. This was primarily due to the relatively small number of recorded cardiovascular-related events across various studies and the wide confidence intervals, reflecting variability in the effects reported (Carll et al., 2022; Daiber et al., 2023; Qiu et al., 2023).

Table 3.

Findings and Limitations for Cardiovascular Outcomes.

Outcome	Research constraints	Reliability of impact	Inaccuracy	Circumlocution	Publication bias	Overall
Arrhythmia	Absence of significant constraints	Absence of notable disparities	Significant uncertainty	Absence of notable disparities	Unbiased reporting	Average
Myocardial infarction	Absence of significant constraints	Absence of notable disparities	Significant uncertainty	Absence of notable disparities	Undetermined	Average
Sudden death	Absence of significant constraints	Absence of notable disparities	Significant uncertainty	Absence of notable disparities	Undetermined	Average

In conclusion, both in vivo and in vitro studies indicate that e-cigarettes, like traditional cigarettes, contribute to cardiovascular damage. Though e-cigarettes may cause milder oxidative stress and endothelial dysfunction, they still pose significant risks for arrhythmias and other cardiovascular complications. Continued research is needed to fully understand the long-term cardiovascular effects of e-cigarettes, especially compared to traditional cigarettes.

Discussion

This study provides a comparative analysis of the cardiovascular risks associated with traditional cigarettes and e-cigarettes, drawing from a broad range of human, in vivo, and in vitro studies. The findings highlight key differences and similarities between these two products in terms of their impact on cardiovascular health.

Traditional cigarettes have long been associated with significant cardiovascular risks, including MI, arrhythmias, and sudden cardiac death (Daiber et al., 2023; El-Mahdy et al., 2021). These outcomes are largely attributed to the high levels of carbon monoxide, oxidant gases, and other harmful substances produced by cigarette smoke, which contribute to oxidative stress and endothelial dysfunction (Daiber et al., 2023; El-Mahdy et al., 2021; Marques et al., 2021). The current analysis reaffirms these established risks while shedding light on the comparatively lower, though still concerning, cardiovascular risks posed by e-cigarettes.

In contrast to traditional cigarettes, e-cigarettes are often marketed as a safer alternative, particularly with regard to respiratory and cardiovascular health. However, this study, along with others in the field, has identified that e-cigarette use is not without its cardiovascular risks (Daiber et al., 2023; Farsalinos & Niaura, 2019). Acute exposure to e-cigarettes has been shown to cause temporary increases in respiratory resistance and decreases in exhaled nitric oxide (FeNO), which are markers of respiratory and cardiovascular strain (Daiber et al., 2023; El-Mahdy et al., 2021; Marques et al., 2021). Moreover, chronic use of e-cigarettes has been linked to higher incidences of arrhythmias compared to non-smokers, suggesting that while e-cigarettes may pose a lesser risk than traditional cigarettes, they are far from benign (Carll et al., 2022; Daiber et al., 2023).

One of the most significant findings in the comparison of TC and EC is their respective impact on oxidative stress and endothelial function. Both in vivo and in vitro studies have demonstrated that traditional cigarette smoke leads to elevated oxidative stress and significant endothelial damage, contributing to atherosclerosis and other CVDs (Chatterjee et al., 2019; Dai et al., 2023; Daiber et al., 2023). E-cigarettes, while causing oxidative stress and endothelial dysfunction, appear to do so to a lesser degree (Dai et al., 2023; Daiber et al., 2023). This suggests that while e-cigarettes may pose a reduced risk of cardiovascular harm compared to traditional cigarettes, they still induce harmful biological responses that could lead to long-term cardiovascular complications.

The collected information revealed that the incidences of arrhythmia, MI, and sudden death were not statistically different between smoking and non-smoking controls, which is consistent with findings from other systematic reviews (Ashraf et al., 2023; Sharma et al., 2023; Vindhyal et al., 2019). A comparable proportion of adverse events was found in studies that did report occurrences, while the bulk of the review’s studies recorded nothing relevant in either the e-cigarette or non-smoking control populations. Regarding the adverse event rates, there were no appreciable variations between the e-cigarette and non-smoking controls in both susceptibility and subgroup evaluations.

Although statistical heterogeneity was found for several outcomes, the results were not significantly affected by it. The only aspect limiting attention was the results’ imprecision, which was evaluated as “moderate.” This imprecision, consistent with other systematic studies (Ashraf et al., 2023; Sharma et al., 2023; Vindhyal et al., 2019), was caused by the low rates of incidence and the broad confidence ranges identified for each outcome. The evaluation is limited by the dearth of articles assessing cardiac events as primary outcomes, medication adherence variations, and limited trial lengths. The prevalence of e-cigarette smoking among different groups might have been impacted by the preponderance of research on smoking cessation.

Despite these drawbacks, the evaluation exhibits several positive characteristics, such as rigorous methodology, adherence to PRISMA principles, and thorough search tactics. All things considered, the results indicate a lack of strong correlations between e-cigarette smoking and dangerous cardiovascular events, offering important new information for both clinical research and future studies. The long-term health impacts of e-cigarette use, particularly with regard to cardiovascular health, require further investigation (Farsalinos & Niaura, 2019; Middlekauff & Gornbein, 2019).

The lack of robust evidence linking e-cigarettes to dangerous cardiovascular events should not be interpreted as an endorsement of their safety, particularly given the known harms of nicotine and other chemicals present in e-cigarette aerosols. Instead, these results should prompt a cautious approach to the promotion of e-cigarettes as a safer alternative to traditional smoking, emphasizing the need for continued surveillance and more rigorous scientific inquiry (Marques et al., 2021).

To provide a more critical analysis of the results, it is important to consider the broader implications of these findings within the context of public health and clinical practice. While the current review did not find statistically significant differences in the incidence of arrhythmia, MI, and sudden death between e-cigarette users and non-smoking controls, this does not necessarily imply that e-cigarettes are without risk (Daiber et al., 2023; Kavousi et al., 2021; Marques et al., 2021).

The moderate imprecision of the results, coupled with the limited number of studies focused specifically on cardiac events as primary outcomes, suggests that the evidence is still evolving. Additionally, the potential for underreporting and the relatively short duration of many studies may mask long-term cardiovascular risks associated with e-cigarette use. Future research should aim to include larger, more diverse populations and longer follow-up periods to better understand the chronic cardiovascular risks associated with e-cigarette use.

Study Implications and Recommendations

Health educators should emphasize the potential cardiovascular risks associated with e-cigarette use, particularly when discussing smoking cessation options with individuals seeking to quit traditional cigarettes. Recent research highlights that while e-cigarettes may be perceived as less harmful than traditional smoking, their cardiovascular effects are still not fully understood, and potential risks remain a concern (Daiber et al., 2023; Elshatarat & Saleh, 2015; Marques et al., 2021). Educators must provide clear and accurate information about the potential dangers, especially regarding cardiovascular health, to guide individuals toward safer smoking cessation options.

Educational programs should include detailed information about the lack of conclusive evidence supporting e-cigarettes as a safer alternative to smoking. It is vital to address the risks associated with dual use (e-cigarettes and traditional cigarettes), as this practice can lead to increased nicotine dependence and prolonged exposure to harmful substances (Buchanan et al., 2020; Elshatarat et al., 2024; Elshatarat & Saleh, 2015). Tailored interventions targeting young adults and adolescents, who are more likely to experiment with e-cigarettes, are especially important. These interventions can play a key role in preventing the initiation of vaping behaviors and in reducing future health risks (Elshatarat et al., 2024; Elshatarat et al., 2016; Elshatarat & Saleh, 2015).

Healthcare professionals, including physicians, nurses, and pharmacists, should be vigilant in monitoring patients who use e-cigarettes, particularly those with pre-existing cardiovascular conditions. Current evidence suggests that while e-cigarettes may pose fewer risks than traditional cigarettes, they are not risk-free (Ashraf et al., 2023; Elshatarat et al., 2024). Clinicians should routinely inquire about e-cigarette use during patient assessments and provide evidence-based counseling on potential cardiovascular risks. Given the limited evidence linking e-cigarette use to major cardiovascular events, healthcare providers should exercise caution in recommending e-cigarettes as a harm reduction tool. Instead, they should prioritize well-established smoking cessation methods that have been proven to be safe and effective (Elshatarat et al., 2024; Elshatarat et al., 2016). Continuous professional development and training are essential to keep healthcare providers updated on the latest research findings regarding e-cigarette use and its cardiovascular impacts.

Clinical researchers should prioritize long-term, large-scale studies that investigate the cardiovascular effects of e-cigarette use, particularly focusing on both acute and chronic outcomes. Research should also address the impact of dual use and examine the cardiovascular effects on populations with varying levels of cardiovascular risk (Elshatarat et al., 2024; Marques et al., 2021). Future studies need to standardize outcome measures to enable more consistent comparisons across research, thus improving the overall quality of evidence. Collaborative efforts among researchers, healthcare providers, and public health officials will be crucial in designing and conducting robust trials to inform clinical guidelines and public health policies related to e-cigarette use (Elshatarat et al., 2024).

Study Limitations

In this comprehensive review, several limitations must be acknowledged. The prevalence of e-cigarette use across different groups may have been influenced by the predominance of studies focused on smoking cessation, which could bias the overall findings. Additionally, the variability in results, marked by wide confidence intervals and low incidence rates, contributed to the evidence being rated as “average.” Despite these limitations, the review exhibits several strengths, including the use of rigorous methodology, adherence to PRISMA guidelines, and comprehensive search strategies. Our findings suggest a lack of strong correlations between e-cigarette use and severe cardiovascular events such as arrhythmia, MI, and sudden death, offering valuable insights for both clinical practice and future research. These results are consistent with previous systematic reviews, supported by aggregated data showing similar rates of adverse events in e-cigarette users and non-smoking control groups. However, potential limitations, such as inadequate medication adherence, short trial durations, and the scarcity of studies focusing on coronary artery disease as a primary outcome, should be considered. Future research with larger sample sizes and longer follow-up periods is necessary to bolster the current body of evidence, although challenges related to feasibility and trial design must be addressed.

Conclusion

This systematic review highlights that both e-cigarettes and traditional cigarettes carry substantial cardiovascular risks. While traditional cigarettes are associated with a higher incidence of MI, arrhythmias, and sudden cardiac death, e-cigarette use also presents significant dangers, particularly due to nicotine and other harmful constituents in the aerosol. E-cigarettes were linked to increased risks of MI and arrhythmias, with notable impacts on heart function, including changes in heart rate variability, blood pressure, and cardiac autonomic regulation. Importantly, the concurrent use of both e-cigarettes and traditional cigarettes was associated with an elevated cardiovascular risk. Though e-cigarettes may pose a somewhat lower risk than traditional cigarettes, they are not without harm, and the long-term effects remain unclear. Further research is crucial to better understand these risks and guide public health recommendations, particularly as e-cigarette use continues to rise.

In terms of practical implications, while the current evidence does not strongly support a link between e-cigarettes and dangerous cardiovascular events, this should not lead to complacency. The absence of strong correlations should be interpreted with caution, and healthcare providers should continue to monitor the long-term cardiovascular effects of e-cigarette use, particularly as its popularity grows. Future research with larger sample sizes and extended follow-up periods is essential to address existing gaps and enhance the evidence base. This will be crucial in guiding clinical decisions and public health policies, ensuring that they are informed by the most comprehensive and reliable data available.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported via funding from Prince Sattam Bin Abdulaziz University project number (PSAU/2023/R/1445).

ORCID iD

Rami A. Elshatarat

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