Clinical testing of the cardiovascular effects of e-cigarette substitution for smoking: a living systematic review

Intern Emerg Med. 2023 Apr;18(3):917-928. doi: 10.1007/s11739-022-03161-z. Epub 2023 Jan 7.


Some persons who smoke have substituted e-cigarettes for tobacco cigarettes, either completely or partially. What effect does this have on cardiovascular functioning? We conducted a living systematic review on human clinical studies measuring the cardiovascular effects of e-cigarette substitution for smoking. The Scopus, PubMed, and CENTRAL Cochrane Library databases were searched on January 31 and April 29, 2021. Three secondary searches and a grey literature search were conducted. Included study designs were randomized controlled trials, quasi-experimental clinical trials, and cohort studies. Risk of bias and study quality were evaluated with the JBI Critical Appraisal tools and the Oxford Catalogue of Bias. The systematic review covered 25 studies comprising 1810 participants who smoked. Twenty studies were rated at high risk of bias, and five as some concerns. A tabular synthesis by direction of effect was conducted due to heterogeneity in the data. Nearly two-thirds of the test analyses indicated that e-cigarette use had no significance difference compared with tobacco cigarettes on heart rate, blood pressure, and in other cardiovascular tests. In two studies, participants with hypertension experienced a clinically relevant reduction in systolic blood pressure after 1 year of e-cigarette use. E-cigarette substitution incurs no additional cardiovascular risks, and some possible benefits may be obtained, but the evidence is of low to very low certainty. An update search on May 30, 2022 retrieved five studies that did not alter our conclusion.Registration PROSPERO #CRD42021239094.

Keywords: Blood pressure; E-cigarette; ENDS; Harm reduction; Heart rate; Living systematic review; Risk of bias.

Publication types

  • Systematic Review

MeSH terms

  • Blood Pressure
  • Cohort Studies
  • Electronic Nicotine Delivery Systems*
  • Humans
  • Hypertension* / drug therapy
  • Smoking / adverse effects
  • Smoking / epidemiology