Advantages and Disadvantages of Electronic Cigarettes.

Despite nearly nine thousand publications on e-cigarettes (EC) in the PubMed database, there is still no consensus in the scientific community and among decision makers regarding the risks and benefits of using these products [...].

Does Alcohol Withdrawal Influence Arterial Stiffness and Classical Risk Factors for Cardiovascular Disease for Persons With Alcohol Use Disorder?

AIMS: The amount and pattern of cigarette and alcohol consumption are highly associated with cardiovascular risk. The aim of the present study was the assessment of changes in arterial stiffness and classical risk factors for cardiovascular disease after alcohol withdrawal and detoxification in persons with alcohol use disorder. METHODS: Two hundred and forty-one individuals (men and women) participated in the investigation. The photoplethysmographic method was applied to assess arterial stiffness in three stages within 6 weeks. Participants were divided into subgroups based on age and sex. Analyses were performed using analysis of variance with repeated measures. RESULTS: Different variations in time of stiffness index (SI) and reflection index (RI) values were recorded. Some increases in triglycerides, total cholesterol, low-density lipoprotein and a decrease in high-density lipoproteins were observed in all analyzed groups. Both systolic and diastolic blood pressure (DP) changed significantly during the 3 weeks of the study only in a group of younger men. The SI is correlated with age and gender. No correlation of RI with sex was found; however, RI was strongly correlated with age, pulse and DP. CONCLUSIONS: The presented study shows that some groups of patients (older women and younger men) after detoxification may be particularly vulnerable to vascular system disorders, i.e. arterial stiffness, making it suggested to include additional observation during therapy.

E-Liquids from Seven European Countries-Warnings Analysis and Freebase Nicotine Content.

Electronic cigarettes are available in a variety of devices with e-liquids also available in many flavors, and nicotine concentrations, albeit less than 20 mg/mL in Europe. Given the dynamics of these products, it is important to evaluate product content, including labeling, nicotine content versus labeled claim, nicotine form, and other aspects that may help policy decisions and align with the Tobacco Product Directive (TPD). Herein, we performed a study on 86 e-liquids from seven European countries (Croatia, Czech Republic, France, Germany, Italy, Poland, and the United Kingdom) with 34 different liquid brands and 57 different flavors. Nicotine content versus labeled claim, labeling, volume, pH, and nicotine form (i.e., freebase nicotine) were evaluated. From all tested products, eight of them from Germany, Poland, and UK (from 3 to 18 mg/mL), met the ±2% criteria. The ±10% criteria was fulfilled by 50 (58.1%) liquids from all countries. Among 71 liquids which contained nicotine, (one e-liquid labeled as 6 mg/mL had no nicotine level quantified), the amount of freebase nicotine differed from 0 to 97.8%, with a mean value 56.5 ± 35.7. None of the tested liquids had nicotine salt listed in the ingredients. Therefore, a low level of freebase nicotine in some liquids was most likely achieved by added flavorings. All tested liquids presented in this study met the basic requirements of the TPD. There were differences in the scope of information about harmfulness, type of warnings on packaging, attaching leaflets, placing graphic symbols, and discrepancies between the declared and quantified nicotine concentrations.

A New Mechanism of the Selective Photodegradation of Antibiotics in the Catalytic System Containing TiO2 and the Inorganic Cations.

The mechanism of sulfisoxazole (SFF) selective removal by photocatalysis in the presence of titanium (IV) oxide (TiO2) and iron (III) chloride (FeCl3) was explained and the kinetics and degradation pathways of SFF and other antibiotics were compared. The effects of selected inorganic ions, oxygen conditions, pH, sorption processes and formation of coordination compounds on the photocatalytic process in the presence of TiO2 were also determined. The Fe3+ compounds added to the irradiated sulfonamide (SN) solution underwent surface sorption on TiO2 particles and act as acceptors of excited electrons. Most likely, the SFF degradation is also intensified by organic radicals or cation organic radicals. These radicals can be initially generated by reaction with electron holes, hydroxyl radicals and as a result of electron transfer mediated by iron ions and then participate in propagation processes. The high sensitivity of SFF to decomposition caused by organic radicals is associated with the steric effect and the high bond polarity of the amide substituent.

Differences in Exposure to Nicotine, Tobacco-Specific Nitrosamines, and Volatile Organic Compounds among Electronic Cigarette Users, Tobacco Smokers, and Dual Users from Three Countries.

Country-level differences in nicotine vaping products used and biomarkers of exposure among long-term e-cigarette users and dual users remain understudied. This cross-sectional study was conducted in 2014 in the United States (n = 166), United Kingdom (n = 129), and Poland (n = 161). We compared patterns of tobacco product use and nicotine and toxicant exposure among cigarette-only smokers (n = 127); e-cigarette-only users (n = 124); dual users of tobacco cigarettes and e-cigarettes (n = 95); and non-users (control group, n = 110) across three countries using mixed-effects linear regression. Compared with cigarette smokers, e-cigarette-only users had lower levels of toxicant biomarkers, but higher levels of nicotine biomarkers. Dual users had higher levels of toxicant biomarkers than e-cigarette-only users but similar levels to cigarette-only smokers. E-cigarette users in Poland, who overwhelmingly used refillable tank devices, exhibited greater levels of nicotine, and toxicant biomarkers relative to e-cigarette users in US/UK. Despite smoking fewer cigarettes, dual users from Poland exhibited similar levels of nicotine biomarkers compared with UK dual users, but higher than US dual users. Country-level differences in e-cigarette devices used and smoking behaviors (e.g., intensity) may contribute to differences in biomarker levels among users of the same products residing in different countries.

E-cigarettes and their impact on health: from pharmacology to clinical implications.

Worldwide, cigarette smoking is the major cause of premature mortality and diseases that can be prevented. Given that people continue smoking despite associated health risks, delivering nicotine without combustion should be considered a valuable and much less harmful way to reduce the public health burden caused by smoking. E­cigarettes could play such a role if they were proven to be less harmful than combustible cigarettes. Although the number of clinical trials and human studies assessing the safety of e­cigarettes is limited, numerous in vitro and in vivo studies reported on the potential harmful effects of the aerosol generated from e­cigarettes. This article reviews the results of major clinical trials and laboratory studies with regard to cancer as well as cardiovascular and respiratory risk associated with the use of e­cigarettes. Additionally, it also discusses the potential application of e­cigarettes as smoking cessation tools. Most studies have indicated so far that e­cigarettes are less harmful, but this applies only to smokers who completely switched to e­cigarettes. In the opinion of the authors, good-quality research is crucial to establish the tolerance, safety, efficacy, and harm reduction potential of new technologies. Considering a significant role that physicians and other health providers play in helping smokers, there is an urgent need for evidence­based guidelines and recommendations for clinical practitioners on potential benefits and risks of e­cigarette use.

Metal Concentration Assessment in the Urine of Cigarette Smokers Who Switched to Electronic Cigarettes: A Pilot Study.

Background: E-cigarettes (ECs) seem to be a less harmful alternative for conventional cigarettes, however, very little is still known about the exposure to some elements, which are the components of this device and may contaminate the nicotine liquid. The aim of this study is to assess whether e-cigarette users are more exposed to 12 elements detected in aerosol than non-smokers and conventional cigarette smokers, using their concentrations in urine as exposure biomarkers. Methods: A cross-sectional, group-based survey was carried out using 90 volunteers classified into groups of non-smokers, EC-only users, dual EC users-cigarette smokers and cigarette-only smokers. Using inductively coupled plasma mass spectrometry (ICP-MS) and electrothermal atomic absorption spectrometry (ETAAS), Cr, Ni, Co, Ag, In, Mn, Ba, Sr, V, Sb, Cd and Pb levels were measured in spot urine samples. Among the selected groups, a comparison was made using the analysis of covariance and correlations with EC usage pattern were assessed by multiple linear regression. Results: Element concentrations in urine of EC-users were not significantly different from the levels found in non-smokers and smokers. Only in the case of Ba, Ni and Sb was a significant correlation found in relation to some e-cigarette usage patterns. Conclusion: Transfer of the investigated elements to the EC aerosol was not found to be a substantial source of exposure in EC users who quitted smoking.

The influence of waste from electronic cigarettes, conventional cigarettes and heat-not-burn tobacco products on microorganisms.

Tobacco smoking, especially conventional cigarettes, is widespread throughout the world. Simultaneously, there is a growing interest in new alternative products that allow delivering nicotine to the users' organisms, including electronic cigarettes and heat-not-burn tobacco products. However, there are few scientific reports regarding the effect of waste generated from the above-mentioned products on microorganisms. The aim of the manuscript was to investigate the influence of substances leached from conventional cigarette butts, butts from heat-not-burn tobacco products, cartridges and e-liquids for electronic cigarettes on microorganisms. The commercial multispecies MARA (microbial assay for risk assessment) test and non-selected microorganisms from the Brynica River (Poland), as well as an effluent from the wastewater treatment plant (Sosnowiec-Zagórze, Poland), were used in the ecotoxicity assessment of the investigated waste. The results of the experiments revealed that the waste from electronic cigarettes, i.e. cartridges and e-liquids, does not pose a considerable threat to the microbiocenosis. On the other hand, a particularly strong ecotoxic effect on the investigated microorganisms has been reported for leachate from smoked cigarette butts and butts from heat-not-burn tobacco products. Their high ecotoxicity combined with a high supply is worrying and it can require interventions to protect the aquatic environment. The retention of the waste can have an adverse effect on microorganisms in reservoirs surface waters or a sludge activity in wastewater treatment plants.

Concentrations of the Selected Biomarkers of Endothelial Dysfunction in Response to Antiepileptic Drugs: A Literature Review.

Epilepsy is a disease arising from morphological and metabolic changes in the brain. Approximately 60% of patients with seizures can be controlled with 1 antiepileptic drug (AED), while in others, polytherapy is required. The AED treatment affects a number of biochemical processes in the body, including increasing the risk of cardiovascular diseases (CVDs). It is indicated that the duration of AED therapy with some AEDs significantly accelerates the process of atherosclerosis. Most of AEDs increase levels of homocysteine (HCys) as well as may affect concentrations of new, nonclassical risk factors for atherosclerosis, that is, asymmetric dimethylarginine (ADMA) and homoarginine (hArg). Because of the role of these parameters in the pathogenesis of CVD, knowledge of HCys, ADMA, and hArg concentrations in patients with epilepsia treated with AED, both pediatric and adult, appears to be of significant importance.

Exposure to Cadmium and Lead in Cigarette Smokers Who Switched to Electronic Cigarettes.

INTRODUCTION: Electronic cigarettes (ECs) seem to be a less harmful alternative for conventional cigarettes. This study aimed to assess whether the generated aerosols from ECs contain lower amount of cadmium (Cd) and lead (Pb) than cigarette smoke and to detect any changes in exposure to Cd and Pb among cigarette smokers who switched completely or partially to EC. METHODS: EC aerosols and cigarette smoke were generated, and the determination of Cd and Pb in trapped samples and e-liquids was performed by the electrothermal atomic absorption spectrometry method. A cross-sectional, group-based survey was carried out using 156 volunteers classified into groups of nonsmokers, EC-only users, dual EC users-cigarette smokers, and cigarette-only smokers. Using electrothermal atomic absorption spectrometry, blood Cd and Pb levels were measured, and the results were compared by analysis of covariance. RESULTS: Transfer of Cd and Pb to EC aerosol was found to be minimal, although the metals were present in the remaining e-liquid from tanks used for vapor generation. The geometric mean blood Cd concentration adjusted for age and sex was 0.44 (95% confidence interval = 0.37 to 0.52) µg/L in the EC-only users, which was significantly lower than those in the smokers of 1.44 (1.16 to 1.78) and dual users of 1.38 (1.11 to 1.72). The blood Pb geometric mean differed significantly only between nonsmokers of 11.9 (10.6 to 13.3) and smokers of 15.9 (13.6 to 18.6). CONCLUSION: The study revealed that smokers who completely switched to ECs and quit smoking conventional cigarettes may significantly reduce their exposure to Cd and probably Pb. IMPLICATIONS: Switching to EC use is associated with a rapid and substantial decrease in the exposure to carcinogenic Cd. Exposure to Pb is probably also decreased but may be overshadowed by other factors. The study provides empirical data based not only on the analysis of generated aerosol but also on biological indicators of recent exposure-that is, the concentrations of Cd and Pb in blood, indicating EC as a potential harm-reduction device, especially regarding Cd exposure. However, in this case, dual EC use-cigarette smoking provides doubtful benefits.

Exclusive versus dual use of tobacco and electronic cigarettes among adolescents in Poland, 2010-2016.

Globally, electronic cigarette (e-cigarette) use among adolescents has increased, along with concerns about potential health implications from exclusive and concurrent tobacco and e-cigarette use (i.e., "dual use"). This study used data from a cross-sectional survey administered to 5708 students aged 15-19 in secondary and technical schools throughout two regions of Poland. Data from 2010-2011 (n = 1760); 2013-2014 (n = 1970) and 2015-2016 (n = 1978) were analyzed to assess changes in use of cigarettes and e-cigarettes from 2010-2016, and correlates of exclusive and dual use, daily use, and intensity of product use from 2013-2016. In this sample, e-cigarette trial and past 30-day exclusive e-cigarette use significantly increased over time (2010-2011: 2%; 2013-2014: 8%; 2015-2016: 11% (p < .05)). Dual use increased from 2010-2011 (4%) to 2013-2014 only (23%, p < .05); and remained stable from 2013-2014 to 2015-2016 (24%, p = .60). Most dual users reported using cigarettes before trying e-cigarettes (82% in 2013-2014, 76% in 2015-2016). Analyses comparing dual users to exclusive users showed significant differences in frequency and intensity of product use, similar findings were observed within dual users. Following the introduction of e-cigarettes, both total tobacco use and total cigarette use increased. Among youth in Poland, e-cigarettes do not seem to replace conventional cigarettes, but instead contribute to a more diverse array of available products from which youth can experiment.

Youth Access to Electronic Cigarettes in an Unrestricted Market: A Cross-Sectional Study from Poland.

Background: Electronic cigarette (e-cigarette) use among youths in Poland has become very popular. The aim of this study was to identify the potential points of access to these products by students aged 16⁻17 years old before implementation of sales restrictions to minors in Poland in November 2016. Methods: A school-based, cross-sectional survey was administered in 2015⁻2016 in 21 secondary/technical schools across two regions of Poland. Analyses focused on 341 students aged 16⁻17 years old who reported their past 30-day use of e-cigarettes. Pearson Chi-square analyses were utilized to examine the associations between access-related items, e-cigarette use and demographics. Results: Among youth e-cigarette users, the most common access to their first e-cigarette was from a friend (38%), followed by purchasing from vape shops (26%). Similar patterns emerged when the students were asked about their access to the currently used e-cigarette. Most youths reported no difficulty in purchasing cartridges/e-liquid containing nicotine (90%). The majority of users (52%) reported buying such products in vape shops. Conclusions: Prior to implementing age-related sales restrictions, youth access to e-cigarettes and paraphernalia did not pose any significant barriers. Poland's introduction of a new age limit on e-cigarette sales may help to limit the number of youths who purchase e-cigarettes from vape shops.

E-cigarettes: voltage- and concentration-dependent loss in human lung adenocarcinoma viability.

E-cigarettes are used by millions of people despite the fact that the harmful effect of aerosol emitted from these products to the human organism is still not clear. In this paper, toxicity of vapor generated using different solutions and battery output voltage on A549 cells viability is presented. The obtained EC50 values for commercially available propylene glycol/glycerol solution 1:1 e-liquids based on 3.2 V (0.127%), 4.0 V (0.112%) and 4.8 V (0.038%) were about 1.5-4.5 times higher than in tobacco smoke (0.0086%). Furthermore, it was shown that the increase of battery output voltage decreased A549 cell viability. In addition, commercially available extracts were more cytotoxic than laboratory made extracts. Owing to the expansiveness of e-cigarettes, it is very important to estimate their impact on public health. Our results not only confirm less cytotoxicity of e-liquid aerosol than cigarette smoke, but also demonstrate that solutions used in e-liquids and, for the first time, battery output voltage have a significant impact on cytotoxicity of e-cigarette vapor. Thus, the results of this study are very important for the current and future legal regulations on e-cigarettes.

Slower nicotine metabolism among postmenopausal Polish smokers.

BACKGROUND: A non-invasive phenotypic indicator of the rate of nicotine metabolism is nicotine metabolite ratio (NMR) defined as a ratio of two major metabolites of nicotine - trans-3'-hydroxycotinine/cotinine. The rate of nicotine metabolism has important clinical implications for the likelihood of successful quitting with nicotine replacement therapy (NRT). We conducted a study to measure NMR among Polish smokers. METHODS: In a cross-sectional study of 180 daily cigarette smokers (42% men; average age 34.6±13.0), we collected spot urine samples and measured trans-3'-hydroxycotinine (3-HC) and cotinine levels with LC-MS/MS method. We calculated NMR (molar ratio) and analyzed variations in NMR among groups of smokers. RESULTS: In the whole study group, an average NMR was 4.8 (IQR 3.4-7.3). The group of women below 51 years had significantly greater NMR compared to the rest of the population (6.4; IQR 4.1-8.8 vs. 4.3; IQR 2.8-6.4). No differences were found among group ages of male smokers. CONCLUSIONS: This is a first study to describe variations in nicotine metabolism among Polish smokers. Our findings indicate that young women metabolize nicotine faster than the rest of population. This finding is consistent with the known effects of estrogen to induce CYP2A6 activity. Young women may require higher doses of NRT or non-nicotine medications for most effective smoking cessation treatment.

Nicotine emissions from electronic cigarettes: Individual and interactive effects of propylene glycol to vegetable glycerin composition and device power output.

INTRODUCTION: The power output of e-cigarettes varies considerably, as does the composition of liquids used with these products. Most e-cigarette liquids contain two primary solvents: propylene glycol (PG) and vegetable glycerin (VG). The primary aim of this study was to examine the extent to which PG and VG composition and device power interact with each other to influence e-cigarette nicotine emissions. METHODS: Aerosols were generated using a 2nd generation e-cigarette and an automatic smoking machine. Nicotine was measured in aerosols, via gas chromatography, produced from three solutions containing pure PG, pure VG, or a mixture of both solvents (50:50) across three different power settings (4.3, 6.7, and 9.6 W). RESULTS: At the lowest power setting, nicotine yield increased significantly as more PG was added to the solution. However, as device power was increased, differences in nicotine yield across liquids became less pronounced. At the highest power setting (9.6 W), nicotine yields did not differ across the three liquids examined. CONCLUSIONS: The present study demonstrated that the extent to which e-cigarette liquid PG and VG composition influences nicotine emissions is dependent on device power. Thus, device power may influence e-cigarette nicotine emissions to a greater degree relative to solvent concentrations.

Removal of veterinary antibiotics from wastewater by electrocoagulation.

The aim of this study was to assess the effectiveness of veterinary antibiotic removal from wastewater using an electrocoagulation method. The removal efficiency of ampicillin, doxycycline, sulfathiazole and tylosin; the antibiotic degradation degree after electrolysis; and the toxicity and qualitative composition of antibiotic solutions after electrocoagulation were determined in the experiments. HPLC-QTOF was used for quantitative and qualitative determination. The eco-toxicity was assessed using the MARA® assay. After electrocoagulation, the concentration of ampicillin, doxycycline, sulfathiazole and tylosin in wastewater decreased 3.6 ± 3.2%, ∼100%, 3.3 ± 0.4% and 3.1 ± 0.3%, respectively. Doxycycline was the only antibiotic effectively removed from wastewater during electrocoagulation. Simultaneously, part of this antibiotic underwent oxidative degradation. As a result of this process, the eco-toxicity in the reaction environment decreased.

Effect of occupational exposure to lead on new risk factors for cardiovascular diseases.

OBJECTIVE: The cardiovascular effects of lead are caused primarily through an effect on blood pressure but are not just limited to an increased risk of hypertension. The aim of our study was to determine to what extent chronic exposure to lead affects new risk factors for cardiovascular disease (CVD) development, such as biomarkers of inflammation (C reactive protein (CRP) and fibrinogen) and biomarkers of endothelial dysfunction (homocysteine, asymmetric dimethylarginine (ADMA) and L-homoarginine). METHODS: A cross-sectional study was performed on a sample of 231 male volunteers, aged 20-60 years, working for at least 2 years in jobs with exposure to lead during the mining and processing of lead-zinc ores. The association between lead in blood and CVD biomarkers was evaluated using multiple linear regression, and the effects of exposure level were observed in workers divided into subgroups according to their blood lead concentration: <250, 250-400 and >400 µg/L. RESULTS: Lead in the blood correlated with new risk factors for CVD except for ADMA. Multiple regression analysis revealed that predictive properties for lead in the blood increased for particular biomarkers in the following order: L-homoarginine, fibrinogen, CRP and homocysteine. Among the specified groups, significant differences were observed only between the groups with the most and least exposure to lead, which differed in concentrations by 54.3% for CRP, 19.3% for fibrinogen, 10.6% for homocysteine and -25.5% for L-homoarginine. CONCLUSIONS: These findings support the hypothesis that occupational exposure to lead can promote atherosclerosis, particularly in highly exposed individuals.

Assessment of the biodegradability of selected sulfa drugs in two polluted rivers in Poland: Effects of seasonal variations, accidental contamination, turbidity and salinity.

The aim of our study was to assess the aerobic biodegradation of four selected sulfonamides (sulfanilamide, sulfamethoxazole, sulfadiazine and sulfathiazole) using water samples drawn from highly polluted rivers. Additionally, we aimed to identify the factors that have a significant effect on the process efficiency. The 19 water samples were collected from Brynica and Czarna Przemsza rivers (in Poland) at the same location at approximately monthly intervals. A characteristic feature of the results is the presence of significant differences between the rates of sulfonamides biodegradation in particular samples. The sulfonamide most resistant to biodegradation was sulfamethoxazole, whereas sulfathiazole was most biodegradable. Seasonal variations and related microbial population changes had the most significant effects on sulfonamides biodegradation, e.g., the studied process was highly inhibited during wintertime. A decrease in the biodegradation rate in the river water could be caused by an accidental water pollution by industrial wastewater with heavy metals, an increase in salinity and a decrease in pH, and turbidity.

Cessation of alcohol consumption decreases rate of nicotine metabolism in male alcohol-dependent smokers.

BACKGROUND: Rate of nicotine metabolism is an important factor influencing cigarette smoking behavior, dependence, and efficacy of nicotine replacement therapy. The current study examined the hypothesis that chronic alcohol abuse can accelerate the rate of nicotine metabolism. Nicotine metabolite ratio (NMR, a biomarker for rate of nicotine metabolism) and patterns of nicotine metabolites were assessed at three time points after alcohol cessation. METHODS: Participants were 22 Caucasian men randomly selected from a sample of 165 smokers entering a 7-week alcohol dependence treatment program in Poland. Data were collected at three time points: baseline (week 1, after acute alcohol detoxification), week 4, and week 7. Urine was analyzed for nicotine and metabolites and used to determine the nicotine metabolite ratio (NMR, a biomarker for rate of nicotine metabolism), and total nicotine equivalents (TNE, a biomarker for total daily nicotine exposure). RESULTS AND CONCLUSIONS: There was a significant decrease in urine NMR over the 7 weeks after alcohol abstinence (F(2,42)=18.83, p<0.001), indicating a decrease in rate of nicotine metabolism. On average NMR decreased 50.0% from baseline to week 7 (9.6±1.3 vs 4.1±0.6). There was no change in urine TNE across the three sessions, indicating no change daily nicotine intake. The results support the idea that chronic alcohol abuse may increase the rate of nicotine metabolism, which then decreases over time after alcohol cessation. This information may help to inform future smoking cessation interventions in this population.

Cherry-flavoured electronic cigarettes expose users to the inhalation irritant, benzaldehyde.

Many non-cigarette tobacco products, including e-cigarettes, contain various flavourings, such as fruit flavours. Although many flavourings used in e-cigarettes are generally recognised as safe when used in food products, concerns have been raised about the potential inhalation toxicity of these chemicals. Benzaldehyde, which is a key ingredient in natural fruit flavours, has been shown to cause irritation of respiratory airways in animal and occupational exposure studies. Given the potential inhalation toxicity of this compound, we measured benzaldehyde in aerosol generated in a laboratory setting from flavoured e-cigarettes purchased online and detected benzaldehyde in 108 out of 145 products. The highest levels of benzaldehyde were detected in cherry-flavoured products. The benzaldehyde doses inhaled with 30 puffs from flavoured e-cigarettes were often higher than doses inhaled from a conventional cigarette. Levels in cherry-flavoured products were >1000 times lower than doses inhaled in the workplace. While e-cigarettes seem to be a promising harm reduction tool for smokers, findings indicate that using these products could result in repeated inhalation of benzaldehyde, with long-term users risking regular exposure to the substance. Given the uncertainty surrounding adverse health effects stemming from long-term inhalation of flavouring ingredients such as benzaldehyde, clinicians need to be aware of this emerging risk and ask their patients about use of flavoured e-cigarettes.