Early Cardiovascular Risk in E-cigarette Users: the Potential Role of Metals

Ana Navas-Acien, Irene Martinez-Morata, Markus Hilpert, Ana Rule, Daichi Shimbo, Nancy J. LoIacono

Research output: Contribution to journalReview articlepeer-review


Purpose of Review: Electronic cigarettes (e-cigs) are a source of metals. Epidemiologic and experimental evidence support that metals are toxic to the cardiovascular system. Little is known, however, about the role that e-cig metals may play as toxicants for the possible cardiovascular effects of e-cig use. The goal of this narrative review is to summarize the evidence on e-cig use and metal exposure and on e-cig use and cardiovascular toxicity and discuss the research needs. Recent Findings: In vitro studies show cytotoxicity and increased oxidative stress in myocardial cells and vascular endothelial cells exposed to e-liquids and e-cig aerosols, with effects partially reversed with antioxidant treatment. There is some evidence that the heating coil plays a role in cell toxicity. Mice exposed to e-cigs for several weeks showed higher levels of oxidative stress, inflammation, platelet activation, and thrombogenesis. Cross-over clinical experiments show e-cig use alters nitric oxide–mediated flow-mediated dilation, endothelial progenitor cells, and arterial stiffness. Cross-sectional evidence from large nationally representative samples in the USA support that e-cig use is associated with self-reported myocardial infarction. Smaller studies found associations of e-cig use with higher oxidized low-density protein and heart variability compared to healthy controls. Numerous studies have measured elevated levels of toxic metals in e-cig aerosols including lead, nickel, chromium, and manganese. Arsenic has been measured in some e-liquids. Several of these metals are well known to be cardiotoxic. Summary: Numerous studies show that e-cigs are a source of cardiotoxic metals. Experimental studies (in vitro, in vivo, and clinical studies) show acute toxicity of e-cigs to the vascular system. Studies of long-term toxicity in animals and humans are missing. Longitudinal studies with repeated measures of metal exposure and subclinical cardiovascular outcomes (e.g., coronary artery calcification) could contribute to determine the long-term cardiovascular effects of e-cigs and the potential role of metals in those effects.

Original languageEnglish (US)
JournalCurrent environmental health reports
StateAccepted/In press - 2020
Externally publishedYes


  • Cardiovascular disease
  • Coronary artery calcification
  • E-cigarettes
  • Endothelial cell health
  • Metals
  • Vaping

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Nature and Landscape Conservation
  • Management, Monitoring, Policy and Law
  • Health, Toxicology and Mutagenesis


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