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Electronic cigarettes and sports: Dangerous liaisons?
International Journal of Cardiology 215 (2016) 400–401
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Electronic cigarettes and sports: Dangerous liaisons?☆ Frédéric Chagué a, Luc Rochette b, Aurélie Gudjoncik a, Yves Cottin a,b, Marianne Zeller b,⁎ a b
Cardiology Department, CHU Dijon, France Laboratory of Cardiometabolic Physiopathology and Pharmacology, INSERM U866, UFR Sciences de Santé, Université Bourgogne-Franche-Comté, Dijon, France
a r t i c l e
i n f o
Article history: Received 6 April 2016 Accepted 10 April 2016 Available online 13 April 2016 Keywords: Nicotine E-cigarettes Sports Cardiovascular effects
Tobacco, including smokeless tobacco (SLT) must be discouraged, especially within 2 h before and after a sports session [1]. However, the guidelines did not include the electronic cigarette (EC) which is a new growing mode of nicotine consumption, used as a smoking cessation tool [3]. Acute exercise is a trigger for myocardial infarction or sudden death, potentially enhanced by nicotine, through increased circulating catecholamine levels [2]. Although controversial and less documented than cigarette smoking (CS) [3], the harmful cardiovascular effects of SLT include coronary events and stroke [4]. Health effects of tobacco are stronger with CS than with SLT and probably than with EC use. In the setting of sports, nicotine delivery is used, supported by its potential beneficial effects on some aspects of performance, appetite control and anxiety reduction. Nicotine delivery through SLT is preferred to CS, given that SLT, in contrast to CS, is devoided of any detrimental action on the respiratory tract. SLT use is increasing in sports such as baseball and ice-hockey [2]. Recent findings from urinary tests in Italian athletes undergoing anti-doping control suggest that new nicotine use through EC delivery might now also be consumed in sports [5]. Although the volume and composition of the aerosol is highly variable according to engineering devices, vapor produced by EC puffing usually includes propylene glycol, nicotine, flavoring agents and particulate matter (Table 1) [4]. Nicotine delivered by EC demonstrates a rapid (b 1 min) arterial peak after an EC puff, followed by an early decrease, not by a prolonged plateau, in contrast to SLT (Fig. 1); this latter kinetics partly explains that SLT is ☆ No financial relationship to disclose. ⁎ Corresponding author at: Laboratory of Cardiometabolic Physiopathology and Pharmacology, INSERM U866, UFR Sciences de Santé, Université Bourgogne-FrancheComté, 7 Bd Jeanne d'Arc, 21079 Dijon, France. E-mail address: [email protected] (M. Zeller).
http://dx.doi.org/10.1016/j.ijcard.2016.04.048 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
used to enhance performance in some sports such as baseball or icehockey. Although a nicotine peak is usually lower than with CS or SLT, higher peaks may be achieved with new electronic devices and some techniques of vaping [3,6]. In athletes performing brief or very brief efforts, such as alpine skiing or ski-jumping, the pharmacokinetic properties of nicotine delivered by EC could provide a beneficial effect. Moreover, EC vaping could be a means to circumvent legislation that prohibits tobacco products in sports federations. Indeed, EC vaping (as tobacco smoking) is more visible than chewing tobacco. Moreover, after 5 min of EC use, inhaled propylene-glycol could impair ventilation through dramatically increased airway resistances [7]. Fine particulate matter (PM) and ultrafine particulate matter generated by EC, although variable and chemically complex, have a size distribution similar to those from CS, EC delivering even more particles than CS [4]. Fine PM from air pollution is known to impair exercise performance in athletes [8] and in CAD patients [9]. However, PM present in CS or air pollution has a different composition than EC-generated particles, and it is not known whether it has the same toxicity as PM found in smoke from CS or air pollution [3]. Only few data have addressed the cardiovascular safety of nicotine delivered by EC. Farsalinos et al. [7] found no deleterious effect on myocardial function and coronary blood flow. Physical exercise increases catecholamine levels, oxidative stress, inflammation and prothrombotic state, and – in the case of underlying endothelial dysfunction – induces a paradoxical vasoconstriction. These effects acutely increase the risk of myocardial ischemia and arrhythmia during sports and recovery [2]. Whether EC consumption could be dangerous during exercise and recovery has not been documented yet. Cardiovascular effects of SLT are related to the ability of nicotine to release catecholamine leading to ischemia and arrhythmias. These effects largely depend on the nicotine arterial peak and, because of an incomplete tolerance phenomenon, on the slope of its raise. Profound EC vaporing could achieve a nicotine arterial peak and a raising slope quite similar to those achieved with CS and SLT. If no plateau effect exists with EC, the hemodynamic response is still significantly present 10 min after EC puffing and it is probably related to an adrenergic stimulation induced by nicotine [6]. Numerous studies and reviews emphasize the increased cardiovascular risk of air pollution exposure, mainly associated with particulate matter concentration and size, which could be enhanced during exercise [10]. Fine (FP, aerodynamic diameter b 2.5 μm) and ultrafine (UFP, b0.1 μm) particles can deposit in pulmonary airways and translocate into the systemic circulation. This translocation could be enhanced by exercise [10]. Endothelial dysfunction has been demonstrated in 16 healthy young adults exposed to FP during a 30 min exercise [8]. As seen above, FP and UFP are found in EC vapor, CS or air pollution. Detrimental
Correspondence
401
Table 1 Chemical components and quantities according to type of cigarette/tobacco consumption and potential effects on cardiovascular system and physical exercise. Component
CS
SLT
EC
CV harmful effects
Effect on physical performance
+++ − − − +/− −
+++ − + + +++ +
+ +++ +++ − Unknown +
↗ or ↘ ↘ ↘ ↘ Unknown Unknown
Quantities Nicotine CO PM Propylene-glycol Aroma Carbonyls
+++ +++ ++ − +/− +++
Fig. 1. Comparative pharmacokinetics of 3 modes of nicotine administration. Adapted from Benowitz et al., 1988 [11] and Saint Helen et al., 2016 [6].
cardiovascular effects of PM could be added to those induced by nicotine and physical exercise. Moreover, PM effects on endothelial function, oxidative stress and inflammation have been shown to be delayed by exercise [8]; so, the detrimental effect of PM produced by vaping before a sports session could occur during exercise or recovery. However, no firm conclusion can be extrapolated to EC, given the wide differences in composition of the mixtures provided by air pollution and EC vapor. Moreover, in contrast to epidemiologic and experimental studies regarding air pollution, no data are available on such effects of EC-produced PM. Carbonyls can be generated by oxidation of an EC liquid when it comes in contact with the heated nichrome wire, with higher levels in high voltage EC; however, these amounts are much lower than those achieved by CS. Heating glycerol contained in EC fluid produces acrolein which is known to have CV deleterious effects; it is not known if amounts of formaldehyde produced by EC can induce a CV risk [3]. In conclusion, given its respiratory effects and the pharmacokinetic profile of nicotine delivery, it seems likely that athletes use EC to quit smoking rather than to enhance performance. However, we cannot exclude that an ergogenic purpose could be aimed in some sports. Although the cardiovascular risk of EC has only been poorly investigated, it could be lower than that of CS. Indeed, we must be aware of hypothetic conflicts of interest of some publications. Moreover, a detrimental cardiovascular effect of EC-produced vapor has not yet been demonstrated before exercise or during recovery, and can only be hypothesized. Further investigations are urgently needed to assess the cardiovascular consequences of EC vaping in the context of physical exercise. Before relevant data are available, it seems wiser to discourage EC vaping (especially brands containing nicotine) before and after physical exercise, particularly in high risk subjects. Funding This work was supported by the University Hospital of Dijon, Association de Cardiologie de Bourgogne, and by grants from the Agence Régionale de Santé (ARS) de Bourgogne, Conseil Régional de Bourgogne, Fédération Française de Cardiologie (FFC) and Société Française de Cardiologie (SFC).
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
References [1] A. Deligiannis, H. Björnstad, F. Carre, H. Heidbüchel, E. Kouidi, N.M. PanhuyzenGoedkoop, F. Pigozzi, W. Schänzer, L. Vanhees, ESC study group of sports cardiology position paper on adverse cardiovascular effects of doping in athletes, Eur. J. Cardiovasc. Prev. Rehabil. 687-94 (2006). [2] F. Chagué, C. Guenancia, A. Gudjoncik, D. Moreau, Y. Cottin, M. Zeller, Smokeless tobacco, sport and the heart, Arch. Cardiovasc. Dis. 108 (2015) 75–83. [3] P.B. Morris, B.A. Ference, E. Jahangir, D.N. Feldman, J.J. Ryan, H. Bahrami, M.F. ElChami, S. Bhakta, D.E. Winchester, M.H. Al-Mallah, M. Sanchez Shields, P. Deedwania, L.S. Mehta, B.A. Phan, N.L. Benowitz, Cardiovascular effects of exposure to cigarette smoke and electronic cigarettes: clinical perspectives from the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology, J. Am. Coll. Cardiol. 66 (2015) 1378–1391. [4] R.A. Grana, P.M. Ling, N. Benowitz, S. Glantz, Electronic cigarettes, Circulation 129 (2014) e490–e492. [5] R. Pacifici, S. Pichini, I. Palmi, X. de la Torre, F. Botrè, Anti-doping Commission at the Ministry of Health. Smoking habits of Italian athletes undergoing anti-doping control, Drug Test. Anal. 8 (2015) 134–136. [6] G. St Helen, C. Havel, D. Dempsey, P. Jacob 3rd, N.L. Benowitz, Nicotine delivery, retention, and pharmacokinetics from various electronic cigarettes, Addiction 111 (3) (2016) 535–544. [7] K.E. Farsalinos, R. Polosa, Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review, Ther. Adv. Drug Saf. 5 (2) (2014) 67–86. [8] K.W. Rundell, Effect of air pollution on athlete health and performance, Br. J. Sports Med. 46 (2012) 407–412. [9] P. Giorgini, M. Rubenfire, R. Das, T. Gracik, L. Wang, M. Morishita, R.L. Bard, E.A. Jackson, C.A. Fitzner, C. Ferri, R.D. Brook, Higher fine particulate matter and temperature levels impair exercise capacity in cardiac patients, Heart 101 (2015) 1293–1301. [10] P. Giorgini, M. Rubenfire, R.L. Bard, E.A. Jackson, C. Ferri, R.D. Brook, Air pollution and exercise: a review of the cardiovascular implications for health care professionals, J. Cardiopulm. Rehabil. Prev. 36 (2016) 84–95. [11] N.L. Benowitz, H. Porchet, L. Sheiner, P. Jacob 3rd, Nicotine absorption and cardiovascular effects with smokeless tobacco use : comparison with cigarettes and nicotine gum. Clin. Pharmacol. Ther. 44 (1988) 23–28.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Electronic cigarettes and sports: Dangerous liaisons?☆ Frédéric Chagué a, Luc Rochette b, Aurélie Gudjoncik a, Yves Cottin a,b, Marianne Zeller b,⁎ a b
Cardiology Department, CHU Dijon, France Laboratory of Cardiometabolic Physiopathology and Pharmacology, INSERM U866, UFR Sciences de Santé, Université Bourgogne-Franche-Comté, Dijon, France
a r t i c l e
i n f o
Article history: Received 6 April 2016 Accepted 10 April 2016 Available online 13 April 2016 Keywords: Nicotine E-cigarettes Sports Cardiovascular effects
Tobacco, including smokeless tobacco (SLT) must be discouraged, especially within 2 h before and after a sports session [1]. However, the guidelines did not include the electronic cigarette (EC) which is a new growing mode of nicotine consumption, used as a smoking cessation tool [3]. Acute exercise is a trigger for myocardial infarction or sudden death, potentially enhanced by nicotine, through increased circulating catecholamine levels [2]. Although controversial and less documented than cigarette smoking (CS) [3], the harmful cardiovascular effects of SLT include coronary events and stroke [4]. Health effects of tobacco are stronger with CS than with SLT and probably than with EC use. In the setting of sports, nicotine delivery is used, supported by its potential beneficial effects on some aspects of performance, appetite control and anxiety reduction. Nicotine delivery through SLT is preferred to CS, given that SLT, in contrast to CS, is devoided of any detrimental action on the respiratory tract. SLT use is increasing in sports such as baseball and ice-hockey [2]. Recent findings from urinary tests in Italian athletes undergoing anti-doping control suggest that new nicotine use through EC delivery might now also be consumed in sports [5]. Although the volume and composition of the aerosol is highly variable according to engineering devices, vapor produced by EC puffing usually includes propylene glycol, nicotine, flavoring agents and particulate matter (Table 1) [4]. Nicotine delivered by EC demonstrates a rapid (b 1 min) arterial peak after an EC puff, followed by an early decrease, not by a prolonged plateau, in contrast to SLT (Fig. 1); this latter kinetics partly explains that SLT is ☆ No financial relationship to disclose. ⁎ Corresponding author at: Laboratory of Cardiometabolic Physiopathology and Pharmacology, INSERM U866, UFR Sciences de Santé, Université Bourgogne-FrancheComté, 7 Bd Jeanne d'Arc, 21079 Dijon, France. E-mail address: [email protected] (M. Zeller).
http://dx.doi.org/10.1016/j.ijcard.2016.04.048 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
used to enhance performance in some sports such as baseball or icehockey. Although a nicotine peak is usually lower than with CS or SLT, higher peaks may be achieved with new electronic devices and some techniques of vaping [3,6]. In athletes performing brief or very brief efforts, such as alpine skiing or ski-jumping, the pharmacokinetic properties of nicotine delivered by EC could provide a beneficial effect. Moreover, EC vaping could be a means to circumvent legislation that prohibits tobacco products in sports federations. Indeed, EC vaping (as tobacco smoking) is more visible than chewing tobacco. Moreover, after 5 min of EC use, inhaled propylene-glycol could impair ventilation through dramatically increased airway resistances [7]. Fine particulate matter (PM) and ultrafine particulate matter generated by EC, although variable and chemically complex, have a size distribution similar to those from CS, EC delivering even more particles than CS [4]. Fine PM from air pollution is known to impair exercise performance in athletes [8] and in CAD patients [9]. However, PM present in CS or air pollution has a different composition than EC-generated particles, and it is not known whether it has the same toxicity as PM found in smoke from CS or air pollution [3]. Only few data have addressed the cardiovascular safety of nicotine delivered by EC. Farsalinos et al. [7] found no deleterious effect on myocardial function and coronary blood flow. Physical exercise increases catecholamine levels, oxidative stress, inflammation and prothrombotic state, and – in the case of underlying endothelial dysfunction – induces a paradoxical vasoconstriction. These effects acutely increase the risk of myocardial ischemia and arrhythmia during sports and recovery [2]. Whether EC consumption could be dangerous during exercise and recovery has not been documented yet. Cardiovascular effects of SLT are related to the ability of nicotine to release catecholamine leading to ischemia and arrhythmias. These effects largely depend on the nicotine arterial peak and, because of an incomplete tolerance phenomenon, on the slope of its raise. Profound EC vaporing could achieve a nicotine arterial peak and a raising slope quite similar to those achieved with CS and SLT. If no plateau effect exists with EC, the hemodynamic response is still significantly present 10 min after EC puffing and it is probably related to an adrenergic stimulation induced by nicotine [6]. Numerous studies and reviews emphasize the increased cardiovascular risk of air pollution exposure, mainly associated with particulate matter concentration and size, which could be enhanced during exercise [10]. Fine (FP, aerodynamic diameter b 2.5 μm) and ultrafine (UFP, b0.1 μm) particles can deposit in pulmonary airways and translocate into the systemic circulation. This translocation could be enhanced by exercise [10]. Endothelial dysfunction has been demonstrated in 16 healthy young adults exposed to FP during a 30 min exercise [8]. As seen above, FP and UFP are found in EC vapor, CS or air pollution. Detrimental
Correspondence
401
Table 1 Chemical components and quantities according to type of cigarette/tobacco consumption and potential effects on cardiovascular system and physical exercise. Component
CS
SLT
EC
CV harmful effects
Effect on physical performance
+++ − − − +/− −
+++ − + + +++ +
+ +++ +++ − Unknown +
↗ or ↘ ↘ ↘ ↘ Unknown Unknown
Quantities Nicotine CO PM Propylene-glycol Aroma Carbonyls
+++ +++ ++ − +/− +++
Fig. 1. Comparative pharmacokinetics of 3 modes of nicotine administration. Adapted from Benowitz et al., 1988 [11] and Saint Helen et al., 2016 [6].
cardiovascular effects of PM could be added to those induced by nicotine and physical exercise. Moreover, PM effects on endothelial function, oxidative stress and inflammation have been shown to be delayed by exercise [8]; so, the detrimental effect of PM produced by vaping before a sports session could occur during exercise or recovery. However, no firm conclusion can be extrapolated to EC, given the wide differences in composition of the mixtures provided by air pollution and EC vapor. Moreover, in contrast to epidemiologic and experimental studies regarding air pollution, no data are available on such effects of EC-produced PM. Carbonyls can be generated by oxidation of an EC liquid when it comes in contact with the heated nichrome wire, with higher levels in high voltage EC; however, these amounts are much lower than those achieved by CS. Heating glycerol contained in EC fluid produces acrolein which is known to have CV deleterious effects; it is not known if amounts of formaldehyde produced by EC can induce a CV risk [3]. In conclusion, given its respiratory effects and the pharmacokinetic profile of nicotine delivery, it seems likely that athletes use EC to quit smoking rather than to enhance performance. However, we cannot exclude that an ergogenic purpose could be aimed in some sports. Although the cardiovascular risk of EC has only been poorly investigated, it could be lower than that of CS. Indeed, we must be aware of hypothetic conflicts of interest of some publications. Moreover, a detrimental cardiovascular effect of EC-produced vapor has not yet been demonstrated before exercise or during recovery, and can only be hypothesized. Further investigations are urgently needed to assess the cardiovascular consequences of EC vaping in the context of physical exercise. Before relevant data are available, it seems wiser to discourage EC vaping (especially brands containing nicotine) before and after physical exercise, particularly in high risk subjects. Funding This work was supported by the University Hospital of Dijon, Association de Cardiologie de Bourgogne, and by grants from the Agence Régionale de Santé (ARS) de Bourgogne, Conseil Régional de Bourgogne, Fédération Française de Cardiologie (FFC) and Société Française de Cardiologie (SFC).
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
References [1] A. Deligiannis, H. Björnstad, F. Carre, H. Heidbüchel, E. Kouidi, N.M. PanhuyzenGoedkoop, F. Pigozzi, W. Schänzer, L. Vanhees, ESC study group of sports cardiology position paper on adverse cardiovascular effects of doping in athletes, Eur. J. Cardiovasc. Prev. Rehabil. 687-94 (2006). [2] F. Chagué, C. Guenancia, A. Gudjoncik, D. Moreau, Y. Cottin, M. Zeller, Smokeless tobacco, sport and the heart, Arch. Cardiovasc. Dis. 108 (2015) 75–83. [3] P.B. Morris, B.A. Ference, E. Jahangir, D.N. Feldman, J.J. Ryan, H. Bahrami, M.F. ElChami, S. Bhakta, D.E. Winchester, M.H. Al-Mallah, M. Sanchez Shields, P. Deedwania, L.S. Mehta, B.A. Phan, N.L. Benowitz, Cardiovascular effects of exposure to cigarette smoke and electronic cigarettes: clinical perspectives from the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology, J. Am. Coll. Cardiol. 66 (2015) 1378–1391. [4] R.A. Grana, P.M. Ling, N. Benowitz, S. Glantz, Electronic cigarettes, Circulation 129 (2014) e490–e492. [5] R. Pacifici, S. Pichini, I. Palmi, X. de la Torre, F. Botrè, Anti-doping Commission at the Ministry of Health. Smoking habits of Italian athletes undergoing anti-doping control, Drug Test. Anal. 8 (2015) 134–136. [6] G. St Helen, C. Havel, D. Dempsey, P. Jacob 3rd, N.L. Benowitz, Nicotine delivery, retention, and pharmacokinetics from various electronic cigarettes, Addiction 111 (3) (2016) 535–544. [7] K.E. Farsalinos, R. Polosa, Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review, Ther. Adv. Drug Saf. 5 (2) (2014) 67–86. [8] K.W. Rundell, Effect of air pollution on athlete health and performance, Br. J. Sports Med. 46 (2012) 407–412. [9] P. Giorgini, M. Rubenfire, R. Das, T. Gracik, L. Wang, M. Morishita, R.L. Bard, E.A. Jackson, C.A. Fitzner, C. Ferri, R.D. Brook, Higher fine particulate matter and temperature levels impair exercise capacity in cardiac patients, Heart 101 (2015) 1293–1301. [10] P. Giorgini, M. Rubenfire, R.L. Bard, E.A. Jackson, C. Ferri, R.D. Brook, Air pollution and exercise: a review of the cardiovascular implications for health care professionals, J. Cardiopulm. Rehabil. Prev. 36 (2016) 84–95. [11] N.L. Benowitz, H. Porchet, L. Sheiner, P. Jacob 3rd, Nicotine absorption and cardiovascular effects with smokeless tobacco use : comparison with cigarettes and nicotine gum. Clin. Pharmacol. Ther. 44 (1988) 23–28.