The following are key points to remember about this review on the effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes:

1. According to the World Health Organization, tobacco including cigarettes, pipes, cigars, waterpipes, smokeless tobacco products, and heated tobacco products kills up to half of its users, which translates into >8 million people annually, of which direct tobacco use accounts for 7 million deaths, and secondhand exposure accounts for 1.2 million deaths. This does not include illness related to e-cigarettes.
2. The prevalence of e-cigarette and waterpipe use has increased dramatically in recent years. Between 2011 and 2015, e-cigarette use has increased more than nine-fold. As of 2014, e-cigarette use is now the most commonly used smoking product in the United States. The prevalence of lifetime waterpipe use has been estimated as high as 44% in the United States, 40% in the United Kingdom, and 29% in Germany.
3. Ample evidence supports the association between tobacco products, including cigarettes and waterpipes and cardiovascular disease (CVD) with endothelial dysfunction, increased oxidative stress, and increased CV morbidity and mortality.
4. Waterpipe smoking is not less harmful than tobacco smoking and thus cannot be considered a healthy alternative. The greater smoke volumes expelled from waterpipe sessions may lead to even higher exposure to toxicants as compared to tobacco cigarette smoking.
5. Short-term evidence suggests harm to the CV system related to e-cigarettes, including increases in blood pressure. E-cigarettes also cause endothelial dysfunction and increase vascular and cerebral oxidative stress. Longer-term evidence is warranted to more fully understand the determinantal effects of e-cigarettes.
6. In addition to nicotine, toxic compounds found in tobacco cigarette smoke, e-cigarette vapor, and waterpipe smoke include carbonyls such as formaldehyde, inorganic compounds (e.g., chromium and lead), and particulate matter. Nicotine, as an alkaloid, increases blood pressure and heart rate, and is associated with endothelial dysfunction. Both tobacco cigarettes and waterpipes burn tobacco, resulting in the production of nitrosamine and polycyclic aromatic hydrocarbons, both groups being known carcinogens and CVD risk enhancers.
7. Tobacco-specific nitrosamines have also been found in nicotine-containing e-cigarette vapor. The main group of toxic compounds responsible for the observed health effects of e-cigarettes are carbonyl compounds.
8. Other groups of toxic compounds found in both tobacco cigarette/waterpipe smoke and e-cigarette vapor are volatile organic compounds and inorganic compounds such as metals and carbon monoxide.
9. The association between tobacco cigarette smoking and CVD has been documented for decades, including through large-scale epidemiologic studies such as the Framingham Heart Study. It should also be noted that extensive evidence supports a similar and comparable association that exists between waterpipe smoking and CVD, including ischemic heart disease and heart failure.
10. Evidence for acute and adverse effects of e-cigarettes on the CV system is well documented; however, the long-term impact of e-cigarettes is currently limited. Furthermore, e-cigarettes have been proposed for use as a tobacco cigarette cessation tool, despite unclear evidence as to the efficacy of such a strategy. A recent large study observed improved smoking cessation rates among participants randomized to e-cigarettes compared to those participants randomized to nicotine replacement. However, the nicotine replacement participants had higher success rates in achieving nicotine cessation altogether, compared to the e-cigarette group.
11. Health policies and regulations for tobacco products vary from country to country and between productions. In the United States, the Food and Drug Administration (FDA) regulates all tobacco products, including waterpipes and e-cigarettes. Lung injury associated with e-cigarettes has been associated with tetrahydrocannabinol (THC) consumption and vitamin E additives; however, many recommendations, including those by the American Heart Association, call for a ban of all e-cigarettes. European recommendations and position statements have been inconsistent regarding recommendations for e-cigarettes.
12. Current evidence suggests that tobacco use may increase the risk for adverse health in coronavirus disease 2019 (COVID-19) infected patients, including increased infection severity and related mortality.
13. Future efforts are recommended to include additional research on the long-term effects of e-cigarettes on CV health, as well as public health interventions to reduce the upward trends in waterpipe use, especially given the evidence that harm related to waterpipe use is similar to that of cigarette use. Efforts to reduce the exposure to secondhand smoke from tobacco products are also warranted.

Clinical Topics: COVID-19 Hub, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Smoking

Keywords: Carbon Monoxide, Coronavirus, COVID-19, Electronic Nicotine Delivery Systems, Electronic Nicotine Delivery Systems, Heart Failure, Lung Injury, Myocardial Ischemia, Nicotine, Primary Prevention, Smoking, Smoking Cessation, Smoke Inhalation Injury, Tobacco, Smokeless

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