Biomarkers of potential harm in people switching from smoking tobacco to exclusive e-cigarette use, dual use or abstinence: secondary analysis of Cochrane systematic review of trials of e-cigarettes for smoking cessation

Addiction. 2023 Mar;118(3):539-545. doi: 10.1111/add.16063. Epub 2022 Oct 21.


Aims: This study aims to compare biomarkers of potential harm between people switching from smoking combustible cigarettes (CC) completely to electronic cigarettes (EC), continuing to smoke CC, using both EC and CC (dual users) and using neither (abstainers), based on behaviour during EC intervention studies.

Design: Secondary analysis following systematic review, incorporating inverse variance random-effects meta-analysis and effect direction plots.

Setting: This study was conducted in Greece, Italy, Poland, the United Kingdom and the United States.

Participants: A total of 1299 adults smoking CC (nine studies) and provided EC.

Measurements: Measurements were conducted using carbon monoxide (CO) and 26 other biomarkers.

Findings: In pooled analyses, exhaled CO (eCO) was lower in EC versus EC + CC [mean difference (MD) = -4.40 parts per million (p.p.m.), 95% confidence interval (CI) = -12.04 to 3.24, two studies] and CC (MD = -9.57 p.p.m., 95% CI = -17.30 to -1.83, three studies). eCO was lower in dual users versus CC only (MD = -1.91 p.p.m., 95% CI = -3.38 to -0.45, two studies). Magnitude rather than direction of effect drove substantial statistical heterogeneity. Effect direction plots were used for other biomarkers. Comparing EC with CC, 12 of 13 biomarkers were significantly lower in EC users, with no difference for the 13th. Comparing EC with dual users, 12 of the 25 biomarkers were lower for EC, and five were lower for dual use. For the remaining eight measures, single studies did not detect statistically significant differences, or the multiple studies contributing to the outcome had inconsistent results. Only one study provided data comparing dual use with CC; of the 13 biomarkers measured, 12 were significantly lower in the dual use group, with no statistically significant difference detected for the 13th. Only one study provided data on abstainers.

Conclusions: Switching from smoking to vaping or dual use appears to reduce levels of biomarkers of potential harm significantly.

Keywords: Electronic cigarettes; biomarkers; carbon monoxide; smoking cessation; systematic review; tobacco.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Biomarkers
  • Clinical Trials as Topic
  • Electronic Nicotine Delivery Systems*
  • Humans
  • Nicotiana
  • Smoking Cessation* / methods
  • Systematic Reviews as Topic
  • Tobacco Products*
  • United States
  • Vaping*


  • Biomarkers