Does vaping with nicotine carry the same risk of thrombosis (blood clot formation) as smoking tobacco?

From the Guidelines

Vaping with nicotine likely carries a lower risk of thrombosis compared to smoking tobacco, but it is not risk-free. The 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease suggests that nicotine e-cigarettes appear to affect endothelial function, vascular stiffness, and blood pressure less than combustible cigarettes 1. However, the guideline also notes that no data are available on the long-term risks of e-cigarettes on overall health and cardiovascular risk, but physiologic and toxicology studies suggest that e-cigarettes may increase cardiovascular risk.

Some key points to consider include:

• Nicotine e-cigarettes are more effective than nicotine replacement therapy (NRT) for smoking cessation, with a relative risk of 1.69 [95% CI, 1.25-2.27] [1]
• Persons using e-cigarettes for smoking cessation are at risk of long-term dependence, with 80% of those assigned to the e-cigarette group still using the device at 1 year 1
• E-cigarettes may increase cardiovascular risk due to their effects on endothelial function, vascular stiffness, and blood pressure, as well as the potential harmful effects of their additives, flavorings, and nicotine dose 1

Given the potential risks and benefits, the safest option for someone concerned about blood clot risk would be to avoid both smoking and vaping. If using vaping as a smoking cessation tool, it should ideally be temporary with the goal of eventually quitting nicotine products entirely. Patients with chronic coronary disease who use e-cigarettes to support smoking cessation should be warned about the risks of developing long-term dependence and encouraged to quit use of e-cigarettes promptly to avoid potential long-term risks 1.

From the Research

Vaping with Nicotine and Thrombosis Risk

• The risk of thrombosis (blood clot formation) associated with vaping nicotine is a concern, with some studies suggesting it may be similar to that of smoking tobacco 2, 3.
• A study published in 1997 found that nicotine may contribute to cardiovascular disease, but the doses of nicotine obtained by regular cigarette smoking generally exceed those delivered by nicotine replacement therapy (NRT), and the cardiovascular effects of nicotine are more intense when delivered rapidly by cigarette smoking than by transdermal nicotine or nicotine gum 2.
• More recent studies have investigated the specific effects of vaping with nicotine on thrombosis risk, with one study finding that exposure to electronic cigarette (EC) aerosol with nicotine significantly increased platelet thrombus formation and fibrin-rich thrombus formation in healthy volunteers 3.
• Another study found that EC vaping was associated with an increased risk of adverse clinical events, including atrial fibrillation and myocardial infarction, although the causal link is still debated 4.
• The evidence suggests that vaping with nicotine may carry a significant risk of thrombosis, although the magnitude of this risk may be lesser than that of traditional tobacco smoking 4, 3.

Comparison to Traditional Tobacco Smoking

• Studies have compared the cardiovascular risk profile of EC vaping to that of traditional tobacco smoking, with some finding that EC vaping may be a temporary lesser evil than traditional tobacco smoking in a risk-reduction or risk-modification strategy 5, 4.
• However, other studies have highlighted the potential dangers of EC vaping, including the risk of thrombosis and other cardiovascular events, and have emphasized the need for comprehensive approaches to harm reduction and regulation 6, 5.
• The evidence suggests that vaping with nicotine is not without risk, and that further research is needed to fully understand the cardiovascular effects of EC vaping 5, 4, 3.