- "Clear" e-cigarettes had disproportionately greater cardiovascular effects than other types of vapes when smoking conditions were controlled.
- "Clear" e-cigarettes contained synthetic coolants, menthol, and other flavorings despite their marketing.
- Acute increases in blood pressure may be related to the synthetic coolants reducing tobacco or nicotine harshness and facilitating deeper inhalation.
E-cigarettes marketed as "clear" may get around flavor bans, but they appear to have a greater health impact than other types of vapes, according to findings from an observational cohort study.
Among participants in the Cardiovascular Injury due to Tobacco Products 2.0 study, smokers of "clear" e-cigarettes had modestly but significantly greater increases in blood pressure, heart rate, and mean arterial pressure (MAP) compared with non-users and peers using menthol and other flavored vapes.
Compared with non-users, the "clear" vapers had acute increases approaching 10 mm Hg in systolic and diastolic blood pressure and MAP, and increases of 10 beats per minute in heart rate, reported Naomi Hamburg, MD, MS, of Boston University, and colleagues in the Journal of the American Heart Association.
"Given prior evidence linking the hemodynamic effects of e-cigarette use to nicotine, it is possible that the presence of synthetic coolants in 'clear' e-cigarettes facilitated inhalation, in turn leading to higher puff volume and thus exposure to e-liquid aerosol and nicotine," the authors wrote.
"The potential that 'clear' e-cigarettes induced more pronounced hemodynamic effects necessitates further study of the health impact of these products and synthetic cooling agents," they concluded.
Flavored tobacco products have been heavily criticized by public health groups, who reason that they are more appealing to teenagers and young people. Menthol flavoring, in particular, has been said to be especially popular among Black people.
While there is no federal ban on flavored tobacco products, restrictions are in place in California, Maryland, Massachusetts, New Jersey, New York, Rhode Island, Utah, and Washington, D.C. Massachusetts, for one, bans the sale of all such products (with the exception of flavored e-cigs sold for on-site consumption at licensed smoking bars).
When explicitly flavored alternatives are not allowed, "clear" vapes may be viewed as especially enticing. Vapes have been found to be less harmful to health than traditional cigarettes, and have boosted smoking abstinence among adults intending to quit smoking.
Hamburg's team reported that they separately purchased 19 "clear" e-cigarettes online and sent them to Connecticut for chemical analysis. With gas chromatography coupled with mass spectroscopy, they found that all 19 contained synthetic cooling agents (e.g., WS-3, WS-23), 18 contained menthol, and 12 contained other flavorants.
"These 'clear' products contained the synthetic, odorless coolants WS-3 and WS-23, menthol, as well as other minty or fruity flavorings, which suggests a violation of the Massachusetts flavored tobacco product regulation," the authors wrote.
"It will be important across studies collecting both sales and epidemiology of e-cigarette use to develop consistent terminology to refer to the group of products labeled as 'clear.' Though manufacturers have not made consistent marketing claims, the 'clear' label could be perceived as an unflavored product," they added.
For this study, Hamburg and colleagues enrolled healthy adults ages 18-45 in Boston and Louisville, Kentucky, who had no established cardiovascular risk factors or cardiovascular disease. Participants were separated into groups of "clear" vape users (n=23), other vape users (n=111), and non-users (n=73).
Average ages were 21, 22, and 26, respectively, and baseline systolic blood pressure was 112, 115, and 110 mm Hg. The participants reported vaping a mean 27 out of the last 30 days.
Each participant was instructed to undergo a 10-minute session in a specialized smoking chamber, during which they were to take one puff of their own vape lasting 3-4 seconds every 30 seconds, or as tolerated. The non-users mimicked smoking using a straw inhaling air.
Acute changes in blood pressure and heart rate were logged immediately following these smoking conditions.
Hamburg's group acknowledged the small number of "clear" e-cigarette users as a limitation of the study.
"Our findings highlight the need for further controlled studies to understand the impact of synthetic cooling agents in e-liquids on the cardiovascular system," they wrote.
isclosures
The study was a project funded by the Yale Tobacco Center of Regulatory Science, the National Institute on Drug Abuse, and the Center for Tobacco Products of the FDA, with additional support from the National Heart, Lung, and Blood Institute and the American Heart Association.
Hamburg and colleagues had no relevant disclosures.
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