Differences between the effects of conventional cigarettes, e-cigarettes and dual product use on urine cotinine levels
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Department of Gerontal Health and Welfare, Pai Chai University, Dae Jeon, Republic of Korea
Institute of Health Insurance and Clinical Research, National Health Insurance Corporation Ilsan Hospital, Goyang, Republic of Korea
Jung-Kyu Choi   

Institute of Health Insurance and Clinical Research, National Health Insurance Corporation Ilsan Hospital, Goyang, Republic of Korea
Publish date: 2019-02-18
Tob. Induc. Dis. 2019;17(February):12
The goal of this study was to evaluate the differences in urine cotinine (UC) concentration based on the use of conventional cigarettes, e-cigarettes (ECs), and dual product use, and determine the use of ECs in the real world.

In total, 15099 subjects were classified into non-smokers, cigarette smokers (c-smokers), e-cigarette smokers (e-smokers), and dual users, and their UC (a classical biomarker of smoking) values were compared. Analysis of covariance (ANCOVA) was performed after adjusting for age, sex and job status to analyze the differences in UC concentration in relation to type of smoking. The reasons for using ECs and the experience of cigarette use before using ECs were analyzed.

Of the 15099 people, 76.4% were non-smokers, 20.9% c-smokers, 2.3% dual users, and 0.4% were e-smokers. There were significant differences in UC concentration among the groups (p<0.001). The geometric mean (GM) UC concentration was 4.45 ng/mL. UC concentration was the highest among dual users (GM: 1030.5, median: 1258.9 ng/mL), followed by c-smokers (GM: 842.5, median: 1163.0 ng/mL), e-smokers (GM: 119.5, median: 309.7 ng/mL), and non-smokers (GM: 0.8, median: 0.8 ng/mL). Among the EC users, the rate of using ECs for health or social convenience was 81.9%. Among e-smokers, 11.4% had never smoked previously.

The UC concentration was the highest among dual users. However, for the female population, the UC concentration was the highest among e-smokers. The vast majority of EC users were dual users. In addition, there were no differences in the frequency of cigarette smoking between the dual user and c-smoker groups. Consequently, EC use did not lead to a decrease in cigarette use, but did lead to an increase in UC concentration. Therefore, in the real world, dual users have higher cotinine levels than the other groups, which could indicate that they take more nicotine by cigarettes or ECs, or are more addicted than others.

Authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.
1. Marsot A, Simon N. Nicotine and cotinine levels with electronic cigarette: a review. International Journal of Toxicology. 2016;35(2):179-185. doi:10.1177/1091581815618935.
2. Rom O, Pecorelli A, Valacchi G, Reznick AZ. Are E‐cigarettes a safe and good alternative to cigarette smoking? Annals of the New York Academy of Sciences. 2015;1340(1):65-74. doi:10.1111/nyas.12609.
3. Rahman MA, Hann N, Wilson A, Mnatzaganian G, Worrall-Carter L. E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis. PloS one. 2015;10(3):e0122544. doi:10.1371/journal.pone.0122544.
4. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;(12):CD010216. doi:10.1002/14651858.cd010216.pub2.
5. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. The Lancet Respiratory Medicine. 2016;4(2):116-128. doi:10.1016/s2213-2600(15)00521-4.
6. El Dib R, Suzumura EA, Akl EA, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis. BMJ Open. 2017;7(2):e012680. doi:10.1136/bmjopen-2016-012680.
7. Moheimani RS, Bhetraratana M, Yin F, et al. Increased cardiac sympathetic activity and oxidative stress in habitual electronic cigarette users: implications for cardiovascular risk. JAMA Cardiology. 2017;2(3):278-284. doi:10.1001/jamacardio.2016.5303.
8. Hua M, Talbot P. Potential health effects of electronic cigarettes: a systematic review of case reports. Preventive Medicine Reports. 2016;4:169-178. doi:10.1016/j.pmedr.2016.06.002.
9. McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update A report commissioned by Public Health England. https://assets.publishing.serv.... Published August, 2015. Accessed June 14, 2018.
10. WHO Framework Convention on Tobacco Control. Electronic nicotine delivery systems. Conference of the Parties to the WHO Framework Convention on Tobacco Control. FCTC/COP/6/10. Published, 2014. Accessed June 14, 2018.
11. Patnode CD, Henderson JT, Thompson JH, et al. Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: a review of reviews for the US Preventive Services Task Force. Annals of Internal Medicine. 2015;163(8):608-621. doi:10.7326/m15-0171.
12. WHO Framework Convention on Tobacco Control. Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS). Conference of the Parties to the WHO Framework Convention on Tobacco Control. FCTC/COP/7/11. Published, 2016. Accessed June 14, 2018.
13. Berry KM, Reynolds LM, Collins JM, et al. E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013–2015. Tobacco Control. 2019;28:42-49. doi:10.1136/tobaccocontrol-2017-054108.
14. Park MB, Kim CB, Nam EW, Hong KS .Does South Korea have hidden female smokers: discrepancies in smoking rates between self-reports and urinary cotinine level. BMC Women's Health. 2014;14(1):156. doi:10.1186/s12905-014-0156-z.
15. Haufroid V, Lison D. Urinary cotinine as a tobacco-smoke exposure index: a minireview. International Archives of Occupational and Environmental Health. 1998;71(3):162-168. doi:10.1007/s004200050266.
16. Changyong F, Hongyue W, Naiji L, et al. Log-transformation and its implications for data analysis. Shanghai Archives of Psychiatry. 2014;26(2):105.
17. Grund B, Sabin C. Analysis of biomarker data: logs, odds ratios, and receiver operating characteristic curves. Current Opinion in HIV and AIDS. 2010;5(6):473-479. doi:10.1097/coh.0b013e32833ed742.
18. Hartmann-Boyce J, Begh R, Aveyard P. Electronic cigarettes for smoking cessation. BMJ. 2018;360:j5543. doi:10.1136/bmj.j5543.
19. Göney G, Çok İ, Tamer U, Burgaz S, Şengezer T. Urinary cotinine levels of electronic cigarette (e-cigarette) users. Toxicology Mechanisms and Methods 2016;26(6):441-445. doi:10.3109/15376516.2016.1144127.
20. Hecht SS, Carmella SG, Kotandeniya D, et al. Evaluation of toxicant and carcinogen metabolites in the urine of e-cigarette users versus cigarette smokers. Nicotine & Tobacco Research. 2014;17(6):704-709. doi:10.1093/ntr/ntu218.
21. McRobbie H, Phillips A, Goniewicz ML, et al. Effects of switching to electronic cigarettes with and without concurrent smoking on exposure to nicotine, carbon monoxide, and acrolein. Cancer Prevention Research. 2015;8(9):873-878. doi:10.1158/1940-6207.capr-15-0058.
22. Polosa R, Caponnetto P, Cibella F, Le-Houezec J. Quit and smoking reduction rates in vape shop consumers: a prospective 12-month survey. International Journal of Environmental Research and Public Health. 2015;12(4):3428-3438. doi:10.3390/ijerph120403428.
23. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11(1):786. doi:10.1186/1471-2458-11-786.
24. Campagna D, Cibella F, Caponnetto P, et al. Changes in breathomics from a 1‐year randomized smoking cessation trial of electronic cigarettes. European Journal of Clinical Investigation. 2016;46(8):698-706. doi:10.1111/eci.12651.
25. Duke JC, Lee YO, Kim AE, et al. Exposure to electronic cigarette television advertisements among youth and young adults. Pediatrics. 2014;134(1):e29-36. doi:10.1542/peds.2014-0269d.
26. Adkison SE, O'Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. American Journal of Preventive Medicine. 2013;44(3):207-215. doi:10.1016/j.amepre.2012.10.018.
27. Robertson L, Hoek J, Blank M-L, Richards R, Ling P, Popova L. Dual use of electronic nicotine delivery systems (ENDS) and smoked tobacco: a qualitative analysis. Tobacco Control. 2018; doi:10.1136/tobaccocontrol-2017-054070.
28. Chapman S. Should electronic cigarettes be as freely available as tobacco cigarettes? British Medical Journal. 2013;346. doi:10.1136/bmj.f3840.
29. Park SH, Lee L, Shearston JA, Weitzman M. Patterns of electronic cigarette use and level of psychological distress. PloS One. 2017;12(3):e0173625. doi:10.1371/journal.pone.0173625.
30. American Academy of Pediatrics. Electronic Nicotine Delivery Systems. Pediatrics. 2015;136(5):1018-1026. doi:10.1542/peds.2015-3222.
31. Padon AA, Lochbuehler K, Maloney EK, Cappella JN. A randomized trial of the effect of youth appealing e-cigarette advertising on susceptibility to use e-cigarettes among youth. Nicotine & Tobacco Research. 2017;20(8):954-961. doi:10.1093/ntr/ntx155.
32. Chen PC, Chang LC, Hsu C, Lee YC. Dual Use of E-Cigarettes and Traditional Cigarettes Among Adolescents in Taiwan, 2014–2016. Nicotine & Tobacco Research. 2018;21(1):48-54. doi:10.1093/ntr/nty003.
33. Sussan TE, Shahzad FG, Tabassum E, et al. Electronic cigarette use behaviors and motivations among smokers and non-smokers. BMC Public Health. 2017;17(1):686. doi:10.1186/s12889-017-4671-3.
34. Pokhrel P, Herzog TA, Fagan P, Unger JB, Stacy AW. E-cigarette Advertising Exposure, Explicit and Implicit Harm Perceptions, and E-Cigarette use Susceptibility Among Non-Smoking Young Adults. Nicotine & Tobacco Research. 2018;21(1):127-131. doi:10.1093/ntr/nty030.
35. Tsikrika S, Vakali S, Gennimata SA, et al. Short term use of an e-cig: influence on clinical symptoms, vital signs and eCO levels. Tob Induc Dis. 2014;12(Suppl 1):A30. doi:10.1186/1617-9625-12-S1-A30.