Am J Physiol Heart Circ Physiol 320: H248–H255, 2021.

First published November 8, 2020; doi:10.1152/ajpheart.00448.2020

RESEARCH ARTICLE

Environmental Inhalants and Cardiovascular Disease

Acute effects of electronic cigarettes on arterial pressure and peripheral

sympathetic activity in young nonsmokers
Joshua E. Gonzalez and William H. Cooke
Department of Kinesiology and Integrative Physiology, Michigan Technological University, Houghton, Michigan

Abstract
Electronic cigarettes (e-cigarettes) are marketed as an alternative to smoking for those who want to decrease the health risks of
tobacco. Tobacco cigarettes increase heart rate (HR) and arterial pressure, while reducing muscle sympathetic nerve activity
(MSNA) through sympathetic baroreflex inhibition. The acute effects of e-cigarettes on arterial pressure and MSNA have not
been reported: our purpose was to clarify this issue. Using a randomized crossover design, participants inhaled on a JUUL e-cig-
arette containing nicotine (59 mg/mL) and a similar placebo e-cigarette (0 mg/mL). Experiments were separated by 1 mo. We
recorded baseline ECG, finger arterial pressure (n = 15), and MSNA (n = 10). Subjects rested for 10 min (BASE) and then inhaled
once every 30 s on an e-cigarette that contained nicotine or placebo (VAPE) for 10 min followed by a 10-min recovery (REC).
Data were expressed as D means ± SE from BASE. Heart rate increased in the nicotine condition during VAPE and returned to
BASE values in REC (5.0 ± 1.3 beats/min nicotine vs. 0.1 ± 0.8 beats/min placebo, during VAPE; P < 0.01). Mean arterial pressure
increased in the nicotine condition during VAPE and remained elevated during REC (6.5 ± 1.6 mmHg nicotine vs. 2.6 ± 1 mmHg
placebo, during VAPE and 4.6.0 ± 1.7 mmHg nicotine vs. 1.4 ± 1.4 mmHg placebo, during REC; P < 0.05). MSNA decreased from
BASE to VAPE and did not restore during REC ( 7.1 ± 1.6 bursts/min nicotine vs. 2.6 ± 2 bursts/min placebo, during VAPE and
5.8 ± 1.7 bursts/min nicotine vs. 0.5 ± 1.4 bursts/min placebo, during REC; P < 0.05). Our results show that acute e-cigarette
usage increases mean arterial pressure leading to a baroreflex-mediated inhibition of MSNA.
NEW & NOTEWORTHY The JUUL e-cigarette is the most popular e-cigarette in the market. In the present study, inhaling on a
JUUL e-cigarette increased mean arterial pressure and heart rate, and decreased muscle sympathetic nerve activity (MSNA). In
contrast, inhaling on a placebo e-cigarette without nicotine elicited no sympathomimetic effects. Although previous tobacco ciga-
rette studies have demonstrated increased mean arterial pressure and MSNA inhibition, ours is the first study to report similar
responses while inhaling on an e-cigarette.
Listen to this article’s corresponding podcast at @ https://ajpheart.podbean.com/e/aerosolized-nicotine-and-cardiovascular-control/.

autonomic control; e-cigarette; JUUL; muscle sympathetic nerve activity

INTRODUCTION agent found in both traditional tobacco cigarettes, and in the

Smoking tobacco cigarettes is a major risk factor for devel-
opment of hypertension, and is the primary cause of prevent-
able cardiovascular disease in the United States (1–3). Smoking
tobacco cigarettes also contributes to sudden serious life-
threatening events such as myocardial ischemia (4) and stroke
(5). One of the primary mechanisms underlying these acute
life-threatening events is smoking-induced sympathetic acti-
vation. Smoking tobacco cigarettes is accompanied by in-
creases in arterial pressure, heart rate, vascular resistance, and
circulating catecholamines (6, 7). Smoking-induced sympa-
thetic activation is associated with an assortment of chemicals
found in tobacco cigarettes, but a dominant constituent is the
nicotine (8). Nicotine is a highly addictive sympathomimetic
fastest growing nicotine product in the United States—elec-
tronic cigarettes (e-cigarettes) (9, 10).
E-cigarettes are marketed aggressively as an alternative to
smoking for those wanting to decrease the serious health
risks associated with tobacco cigarettes. However, although
e-cigarette usage has increased in smokers attempting to
quit tobacco cigarettes, it has also increased in nonsmoking
young adults. Among young adults, the JUUL is the most-
used brand of e-cigarette (11). JUUL is the largest e-cigarette
brand in the United States, capturing more than half of the
e-cigarette market (12). Although e-cigarettes do not deliver
the numerous carcinogens of traditional tobacco cigarettes
(13), they do contain high amounts of nicotine—and nicotine
is not innocuous.

Correspondence: W. H. Cooke (wcooke@mtu.edu).

Submitted 10 June 2020 / Revised 3 November 2020 / Accepted 5 November 2020

H248 0363-6135/21 Copyright © 2021 the American Physiological Society http://www.ajpheart.org

Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL
A recent study by Moheimani et al. (14) showed that
increased cardiac sympathetic activation (using spectral
analysis of heart rate variability as an estimate) caused by e-
cigarettes was due to the nicotine, and not due to the other
e-liquid constituents such as propylene glycol (PG) and vege-
table glycerin (VG). Previous studies have also shown that e-
cigarettes increase arterial pressure and heart rate (15).
However, direct sympathetic neural outflow has yet to be
measured during acute inhalation of aerosolized nicotine
from an e-cigarette: this limitation has been highlighted in a
recent review by Garcia et al. (16).
The purpose of our study was to investigate how acute in-
halation on the JUUL e-cigarette affects arterial pressure and
sympathetic neural outflow in young, healthy nonsmokers.
Based in part on the previous work by Narkiewicz et al. (17),
we tested the hypothesis that inhaling nicotine from the
JUUL e-cigarette increases arterial pressure and decreases
muscle sympathetic nerve activity (MSNA) acutely.
METHODS
Participants
Fifteen healthy young adults (nine males, six females, aged
21 ± 1 yr, height = 174 ± 3 cm, and weight = 78 ± 4 kg) partici-
pated. All participants had no history of autonomic dysfunc-
tion, hypertension, respiratory disease, diabetes, tobacco, or
vaporized nicotine usage, and were not taking any prescribed
medications. Participants were screened for hypertension
(systolic <130 and/or diastolic <80) via three-seated blood
pressures taken with an automated sphygmomanometer
(Omron Healthcare, Lake Forest, IL). All female participants
were tested during the early-follicular phase of their men-
strual cycle. Participants were instructed to abstain from exer-
cise and caffeine for 24 h before laboratory testing. All
participants signed a consent form that had been approved by
the Institutional Review Board for human subject research at
Michigan Technological University.
Instrumentation
Beat-to-beat arterial blood pressure was recorded continu-
ously throughout all time points using a NOVA Finometer
(Finapres Medical Systems, Amsterdam, The Netherlands).
Heart rate was recorded continuously via a three-lead elec-
trocardiogram, and respiratory rate was continuously meas-
ured using a pneumobelt.
Cotinine Detection
About 70%–80% of active nicotine is metabolized to
cotinine; this surrogate biomarker is easily measured to
represent active nicotine levels (18). Whole blood cotinine
concentration was measured with a PTS Detect Cotinine
System (PTS Diagnostics, Indianapolis, IN), a device capa-
ble of measuring blood cotinine levels from 25 ng/mL to
200 ng/mL. Whole blood cotinine was measured before
the start of the experiment, immediately after the vaping
protocol, and after the recovery period. After the recovery
period, subjects were asked the open-ended question,
“how are you feeling,” and their subjective responses were
recorded.
AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org
Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
Microneurography
Multifiber efferent sympathetic nerve traffic was recorded
from the peroneal nerve muscle fascicles at the popliteal
fossa by inserting a tungsten microelectrode (Frederick Haer
and Co., Bowdoninham, ME). A reference electrode was
inserted subcutaneously 2–3 cm from the recording elec-
trode. Both electrodes were connected to a differential pre-
amplifier and then to an amplifier (total gain 80,000) where
the nerve signal was bandpass filtered (700–2,000 Hz) and
integrated (time constant, 0.1 s) to obtain a mean voltage dis-
play of nerve activity. Satisfactory recordings of MSNA were
defined by spontaneous pulse-synchronous bursts that did
not change during tactile or auditory stimulation and
increased during end-expiratory apnea.
Experimental Design
Each participant was tested twice; once with a JUUL e-ciga-
rette containing 59 mg/mL of nicotine and once with an e-cig-
arette containing 0 mg/mL of nicotine. Trial order (nicotine
vs. placebo) was randomized, and tests were performed
1 mo apart. Plasma cotinine was measured to ensure that
participants had not been exposed to any tobacco products
before using the e-cigarette. Participants were then situated
in a semirecumbent position on a cushioned laboratory table
for hemodynamic and microneurographic instrumentation.
After instrumentation, all participants were provided a mini-
mum of 5-min nonrecorded rest to confirm hemodynamic
and neural stability. Throughout the experiment, participants
breathed in time to a computer display showing a waveform
set at 0.25 Hz (15 breaths/minute). A 10-min baseline was
recorded followed by a 10-min inhalation protocol. During
the inhalation protocol, participants were asked to inhale
once every 30 s on the device for a total of 20 inhalations
while keeping in time with the computer display. Timing of
inhalation was prompted by an investigator to ensure that
accurate control of breathing frequency was maintained.
After the inhalation protocol, a 10-min recovery was recorded,
and participants were asked to report any symptoms resulting
from e-cigarette inhalation.
E-Cigarette Devices and E-Liquid
All participants used the JUUL vape pod system as the nic-
otine delivery device and the SMOK FIT Kit vape pod system
as the placebo delivery device. SMOK FIT Kit was used to
deliver the placebo because JUUL currently does not make a
pod compatible with their system that does not contain nico-
tine. Mango flavored JUUL pods (30PG/60VG) containing 59
mg/mL of nicotine were used as the nicotine intervention.
Mango flavored Naked e-liquid (30PG/70VG) was used as the
placebo containing 0 mg/mL of nicotine in the SMOK FIT Kit
pods. The placebo e-cigarette SMOK FIT Kit has a variable
voltage (10–16 V) as a protective mechanism that automati-
cally varies the wattage based on the device charge level.
Although this is not manually controllable, to be consistent
both devices were fully charged before each experiment.
Data Analysis
Data were sampled at 500 Hz (WINDAQ, Dataq Instru-
ments, Akron, OH) and analyzed with specialized software
H249
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL
(WINCPRS, Absolute Aliens, Turku, Finland). R waves gener-
ated from the ECG signal were automatically detected and
marked. Systolic and diastolic arterial pressures were
marked from the Finometer tracings. Muscle sympathetic
nerve bursts were automatically detected based on their am-
plitude and a 1.3-s expected burst peak latency from the pre-
vious R wave. All automated detection results were checked
manually. Sympathetic bursts of activity were expressed as
burst frequency (bursts/min) and burst incidence (bursts/
100 heartbeats). Data were averaged from the last 5 min of
every 10-min time period.
Spontaneous cardiovagal baroreflex sensitivity (cBRS) was
calculated using linear regression. Three or more progressive
changes of systolic arterial pressure (SAP) and corresponding
changes of RRI were identified as baroreflex sequences. In
this study, both up-up (increase in SAP followed by length-
ening of the RRI interval) and down-down (decrease in SAP
followed by a shortening of the RRI interval) sequences were
assessed. Adequate baroreflex sequences were defined as a
minimum of 1 mmHg change in SAP and a minimum of 5 ms
change in RRI. A minimum r value of 0.7 was used as criteria
for accepting sequences.
Using a two-sample t test to estimate power based on data
from a previous publication (15), we estimated that a sample
size of 16 subjects would give us sufficient power (0.8).
Statistical analyses were performed with Sigmaplot 14.0
(Systat Software, San Jose, CA). Dependent variables of inter-
est were assessed with a 2 (Condition; Nicotine or Placebo)
by 3 (Time; Baseline, Vape, Recovery) repeated-measures
ANOVA. Significant interactions were assessed using a
Student–Newman–Keuls post hoc test. Data are presented as
means ± SE. A probability value 0.05 was considered statis-
tically significant.
RESULTS
A representative tracing of data recorded continuously
throughout the protocol is shown for one subject during 2
Figure 1. Raw data tracings are shown for one sub-
ject during baseline for arterial pressure and muscle
sympathetic nerve activity (MSNA).
H250 AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org
Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
min of resting at baseline in Fig. 1. Figure 1 shows the charac-
teristic inverse relation between arterial pressure and MSNA.
In a previous study, Cooke et al. (15) found minimal, but
significant increases in urine cotinine concentrations using
an identical inhalation protocol. For that reason, we chose to
use cotinine again as our biomarker. In the previous study
by Cooke et al. (15), urine was collected before instrumenta-
tion of the subject. In the current study, collection of urine
was not possible because subjects were instrumented first, in
an attempt to normalize the protocol with respect to the
amount of time required to obtain an appropriate nerve re-
cording. In the current study, we did not detect increases in
whole blood cotinine concentrations. All participant’s blood
cotinine concentrations at baseline, vape, and recovery were
measured at <25 ng/mL for both conditions. However, the
subjective symptoms reported by subjects suggest successful
nicotine exposure. After inhaling on the JUUL, 11 out of 15
participants reported feeling light-headed, and the other par-
ticipants reported throat irritation as their primary subjec-
tive symptom. No symptoms were reported by any subject
after inhalation on the placebo e-cigarette.
During inhalation on the JUUL, heart rate and mean arte-
rial pressure increased, but did not change during inhalation
on the placebo e-cigarette. Following the use of the JUUL,
heart rate returned to baseline, but mean arterial pressure
remained significantly elevated compared with placebo
throughout recovery. Cardiovagal baroreflex sensitivity cal-
culated from SAP-RRI down sequences (but not up sequen-
ces) was reduced significantly with JUUL vaping. The effect
of vaporized nicotine from the JUUL and placebo on muscle
sympathetic nerve discharge was determined in 10 of the 15
participants due to complexities associated with recording
MSNA twice in all subjects. During inhalation on the JUUL,
burst incidence and burst frequency declined abruptly, and
remained suppressed into recovery. While inhaling on the
placebo, participants did not show any significant changes
in MSNA. The marked decrease in MSNA activity with nico-
tine inhalation was paralleled by increases in mean arterial
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL

Table 1. Average autonomic cardiovascular and hemodynamic data recorded during baseline, vape, and recovery
Baseline Vaping Recovery Time Condition  Time
Placebo E-Cigarette
Systolic blood pressure, mmHg 119 ± 4 122 ± 4 121 ± 4 0.210
Diastolic blood pressure, mmHg 68 ± 2 70 ± 2 69 ± 3 0.229
Mean arterial pressure, mmHg 88 ± 3 90 ± 3 89 ± 3 0.108
Heart rate, beats/min 75 ± 4 75 ± 4 74 ± 4 0.120
MSNA, bursts/min 20 ± 2 21 ± 2 20 ± 2 0.276
MSNA, bursts/100 heartbeats 29 ± 3 31 ± 3 29 ± 3 0.327
cBRS-up, ms/mmHg 13 ± 1 12 ± 2 14 ± 2 0.251
cBRS-down, ms/mmHg 13 ± 2 12 ± 2 13 ± 2 0.152
JUUL E-Cigarette
Systolic blood pressure, mmHg 120 ± 5 126 ± 5 124 ± 5 0.021 0.244
Diastolic blood pressure, mmHg 66 ± 3 72 ± 2 70 ± 2 0.001 0.051
Mean arterial pressure, mmHg 86 ± 3 92 ± 3 91 ± 3 0.001 0.044
Heart rate, beats/min 74 ± 3 79 ± 3† 75 ± 3 0.002 0.001
MSNA, bursts/min 22 ± 2 18 ± 2 17 ± 2 <.001 0.003
MSNA, bursts/100 heartbeats 31 ± 3 24 ± 3† 25 ± 3 0.001 0.004
cBRS-up, ms/mmHg 14 ± 2 12 ± 1 13 ± 2 0.093 0.318
cBRS-down, ms/mmHg 12 ± 1 9 ± 1 12 ± 2 0.030 0.806
Time and condition  time show associated probability values. cBRS, cardiovagal baroreflex sensitivity; MSNA,muscle sympathetic
nerve activity. Significant differences within a condition (vaping vs. baseline and recovery vs. baseline). †Significant differences
between condition  time.

pressure during both inhalation and recovery. These data
are shown in Table 1.
In an effort to display reducibility of nerve recordings
between the same subjects at the same 30 s time points during
both nicotine and placebo trials, we plotted sympathetic neu-
rograms and associated mean arterial pressures for three dif-
ferent subjects. These neurograms are shown in Fig. 2.
Figure 3 shows MSNA, mean arterial pressure, and heart
rate responses for one representative subject during the
course of the experiment. Responses were consistent within
groups, and Fig. 4 shows group-averages represented as
changes from baseline.
DISCUSSION
We asked young, healthy nonsmokers to inhale, in a pre-
scribed way, on a JUUL e-cigarette containing nicotine, and
on a similar nonnicotine-containing device. Our purpose
was to clarify cardiovascular control mechanisms and pe-
ripheral sympathetic activity during e-cigarette nicotine in-
halation. We report two novel findings: 1) inhalation on the
JUUL e-cigarette induces a marked and sustained arterial
pressor response and 2) the pressor response is accompanied
by an inhibition of MSNA. We demonstrate that acute
increases in arterial pressure and reduction in peripheral
sympathetic activity are attributable to the inhaled nicotine,
and not to the non-nicotine solvents included in e-cigarettes.
To our knowledge, our study is the first to report both
increases of arterial pressure and reductions of MSNA during
acute nicotine inhalation. Smoking tobacco cigarettes results
in potent sympathomimetic influences on hemodynamics
and autonomic neural regulation. It is well known that com-
bustible tobacco cigarettes induce sharp increases in mean
arterial pressure, while inhibiting MSNA (7, 19). Grassi et al.
(7) and Niedermaier et al. (19) showed that acute increases in
mean arterial pressure associated with traditional cigarette
inhalation inhibit peripheral MSNA through sympathetic
baroreflex inhibition. Sympathetic baroreflex inhibition
consequent to smoking was confirmed in an elegant study
by Narkiewicz et al. (17). In that study, smoking caused
expected increases of mean arterial pressure and reductions
of MSNA. However, when arterial pressure increases were
inhibited with nitroprusside infusion MSNA increased
approximately threefold, confirming for the first time clear
sympathomimetic effects of cigarette smoking (17).
Increases in MSNA in response to tobacco cigarette smok-
ing have also been demonstrated in humans with impaired
baroreflex function (20). In addition, acute and chronic
tobacco use itself reduces cardiovagal BRS (21, 22). Mancia et
al. (23), for example, demonstrated reduced baroreflex sensi-
tivity in subjects who smoked four cigarettes in 1 h. Such
reduced sensitivity could underlie marked arterial pressor
responses and could complicate arterial pressure regulation
during activities of daily living. In the present study, dynamic
baroreflex sensitivity changed minimally. Baroreflex up-
sequences (increased cardiovagal activity) were not affected
by e-cigarette inhalation, but baroreflex down-sequences
(decreased cardiovagal activity) were reduced from 12 ms/
mmHg to 9 ms/mmHg (Table 1). Whereas reduced R-R inter-
val responsiveness to reductions in pressure could adversely
affect responses to stimuli such as orthostasis, our finding of a
reduction of 3 ms/mmHg, although statistically significant,
may not be clinically relevant.
Heart rate was not decreased as might be expected
through baroreflex inhibition. However, nicotine induces
catecholamine release from the adrenal medulla and
increases the sensitivity of cardiac sympathetic nerves to
catecholamines (24).
In conjunction, these two effects of nicotine work to
increase heart rate and myocardial contractility. Although
the baroreflex will attempt to buffer increases in heart rate,
direct sympathetic stimulation of nicotine may overcome
the buffering effect of the baroreflex on heart rate.
It is important to note that tobacco cigarettes contain over
7,000 chemical agents with both nicotine and fine particu-
late matter (PM2.5) contributing to sympathoexcitation (25,

AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org H251

Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL

Figure 2. Raw integrated neurograms and corre-

sponding mean arterial pressures (MAPs) are shown
for three participants during the same 30-s time points
during placebo and nicotine inhalations.

26). By comparison, e-cigarettes contain relatively few chem-
ical agents, with the only known sympathomimetic agent
being nicotine (14). In healthy humans, Moheimani et al. (14)
expressed heart rate variability in the frequency domain after
subjects inhaled on an e-cigarette containing nicotine, and
after they inhaled on an e-cigarette containing no nicotine.
Heart rate variability at the high frequency decreased, and
heart rate variability at the low frequency increased after nic-
otine, but not placebo inhalation. These data were inter-
preted as heightened cardiac sympathetic activity directly
related to nicotine. Although low-frequency spectral power
is only an estimate of sympathetic contributions to heart rate
variability and its physiological relevance has been ques-
tioned (27), the technique has been widely used (28).
Building on the assumption that sympathomimetic effects of
e-cigarettes are related directly to inhaled nicotine, we per-
formed a study similar to Moheimani et al. (14), in that
subjects inhaled on both a nicotine and placebo e-cigarette.
The increases in mean arterial pressure and heart rate, in
conjunction with reductions in MSNA we document while
subjects are using an e-cigarette are similar to results shown
by Grassi et al. (7) and Niedermaier et al. (19) in subjects
inhaling traditional tobacco cigarettes.
The advent of e-cigarettes is still new, and the chronic
health consequences associated with e-cigarette use have
yet to be determined. Clinical trials have suggested that
e-cigarettes are an effective cessation aid for tobacco
smokers (29, 30), and more effective in this regard than
more traditional nicotine replacement therapies (31).
Nevertheless, our results indicate that the acute arterial
pressor response to e-cigarettes mirror those of traditional
tobacco cigarettes. Our results are particularly concerning
given the increased usage of e-cigarettes among young
nonsmokers (10, 11).

H252 AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org

Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL

baroreflexes. In populations whose baroreflex function is

attenuated, it is likely that e-cigarette usage would cause
exaggerated sympathoexcitation and thus be detrimental to
cardiovascular health. While it is unknown if this demon-
strated response is more deleterious than other nicotine
replacement therapies, research investigating chronic e-ciga-
rette use is needed to further understand potential cardio-
vascular risks.
Limitations
We did not measure plasma nicotine levels. We attempted
to use cotinine as a biomarker for nicotine absorption as
Cooke et al. (15) had done with urine cotinine concentrations
in an early study. Future studies investigating acute e-ciga-
rette usage should utilize plasma nicotine as the biomarker
for absorption. This is especially important for establishing a
nicotine dose-response curve for arterial pressure, heart rate,
and peripheral sympathetic activity. Using an intravenous
line for periodic blood sampling, a recent publication dem-
onstrated that nicotine absorption during 5 min of ad libi-
tum JUUL e-cigarette usage is remarkably similar to tobacco
cigarettes (35).
Independent chemical analysis of the JUUL pods and the
placebo e-liquid was not conducted. Other studies have
found that JUUL pods have variable nicotine content that
may be different from the company’s advertised 59 mg/mL.
Nicotine concentrations in JUUL pods have been reported to
be 56.2 (36), 61.6 ± 1.5 (37), and 68.6 ± 2.3 (38) (means ± SE).

Nicotine
Figure 3. One minute averages are shown over the course of the experi- Placebo
MAP (mmHg)

ment for heart rate, blood pressure, and muscle sympathetic nerve activity
(MSNA) during baseline, vape, and recovery for one subject.

Participants in our study vaped in a prescribed pattern

and were nonsmokers, and thus naïve to e-cigarettes and
nicotine. Experience with e-cigarettes and vaping patterns
are important factors that impact nicotine absorption and e-
MSNA (bursts/min)

cigarette puffing topography. Experienced e-cigarette users

can significantly increase their nicotine absorption in acute
vaping sessions compared with inexperienced users (32).
Within 4 wk of experience with a device, new e-cigarette
users increase their peak plasma nicotine concentrations by
24% in acute ad libitum vaping sessions, compared with
their first week of usage (33, 34). Puffing topography also
changes within a week of using e-cigarettes with new users
taking longer and slower puffs on the device (34). Experience
HR (bpm)

with e-cigarette devices increases puff duration and peak

nicotine absorption, thus by using naïve participants, our
results could potentially be an underestimation of the hemo-
dynamic and neurovascular responses that would be exhib-
ited in experienced e-cigarette users.
In conclusion, acute inhalation of nicotine from the JUUL
Inhalation Recovery
e-cigarette increases mean arterial pressure and heart rate
and inhibits peripheral MSNA. Inhalation on an e-cigarette Figure 4. Group-average changes from baseline to vape and recovery are
that does not contain nicotine does not elicit sympathoexcit- shown for mean arterial pressure (MAP; n = 15), muscle sympathetic nerve
activity (MSNA; n = 10), and heart rate (HR; n = 15). Dependent variables of
atory responses and does not influence peripheral sympa- interest were assessed using a two-way repeated-measured ANOVA.
thetic outflow. These observed responses are likely due to Significant interactions were assessed using a Student–Newman–Keuls
our population being young healthy adults with intact post hoc test; P < 0.05 vs. corresponding placebo value.

AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org H253

Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL
We estimated an appropriate sample size of 16 subjects,
but only studied 15 (10 with complete nerve recordings for
both conditions). During data collection in the summer of
2019, a rash of cases of severe lung injury and even death
were reported in the United States. This outbreak of cases
was termed EVALI (e-cigarette or vaping product use associ-
ated lung injury) (39). Because the causes of these adverse
events were not known at the time, our local Institutional
Review Board suspended our study before we were able to
reach our target enrollment.
ACKNOWLEDGMENTS
We thank Stephanie Renee Jewell for technical assistance on
the project.
The study has Clinical Trials Registration No. NCT04613609.
GRANTS
This study was funded by a grant from Blue Cross Blue Shield
of Michigan and by an endowment from the Portage Health
Foundation, Houghton Michigan.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared by
the authors.
AUTHOR CONTRIBUTIONS
J.E.G. and W.H.C. conceived and designed research; J.E.G. and
W.H.C. performed experiments; J.E.G. and W.H.C. analyzed data;
J.E.G. and W.H.C. interpreted results of experiments; J.E.G. and
W.H.C. prepared figures; J.E.G. and W.H.C. drafted manuscript;
J.E.G. and W.H.C. edited and revised manuscript; J.E.G. and
W.H.C. approved final version of manuscript.
REFERENCES
1. Berry JD, Dyer A, Cai X, Garside DB, Ning H, Thomas A, Greenland
P, Van Horn L, Tracy RP, Lloyd-Jones DM. Lifetime risks of cardio-
vascular disease. N Engl J Med 366: 321–329, 2012. doi:10.1056/
NEJMoa1012848.
2. Kannel WB, Higgins M. Smoking and hypertension as predictors of
cardiovascular risk in population studies. J Hypertens 8: S3–S8,
1990. doi:10.1097/00004872-199003001-00002.
3. Thun MJ, Carter BD, Feskanich D, Freedman ND, Prentice R,
Lopez AD, Hartge P, Gapstur SM. 50-year trends in smoking-
related mortality in the United States. N Engl J Med 368: 351–364,
2013. doi:10.1056/NEJMsa1211127.
4. Gabbay FH, Krantz DS, Kop WJ, Hedges SM, Klein J, Gottdiener
JS, Rozanski A. Triggers of myocardial ischemia during daily life in
patients with coronary artery disease: physical and mental activities,
anger and smoking. J Am Coll Cardiol 27: 585–592, 1996.
doi:10.1016/0735-1097(95)00510-2.
5. Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. Passive
smoking as well as active smoking increases the risk of acute stroke.
Tob Control 8: 156–160, 1999. doi:10.1136/tc.8.2.156.
6. Cellina GU, Honour AJ, Littler WA. Direct arterial pressure, heart
rate, and electrocardiogram during cigarette smoking in unrestricted
patients. Am Heart J89: 18–25, 1975. doi:10.1016/0002-8703(75)
90004-6.
7. Grassi G, Seravalle G, Calhoun DA, Bolla GB, Giannattasio C,
Marabini M, Del Bo A, Mancia G. Mechanisms responsible for
H254 AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org
Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
sympathetic activation by cigarette smoking in humans. Circulation
90: 248–253, 1994. doi:10.1161/01.CIR.90.1.248.
8. Benowitz NL. The role of nicotine in smoking-related cardiovascular
disease. Prev Med 26: 412–417, 1997. doi:10.1006/pmed.1997.0175.
9. Creamer MR, Wang TW, Babb S, Cullen KA, Day H, Willis G, Jamal
A, Neff L. Tobacco product use and cessation indicators among
adults—United States, 2018. MMWR Morb Mortal Wkly Rep 68:
1013–1019, 2019. doi:10.15585/mmwr.mm6845a2.
10. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King
BA. Notes from the Field: Use of electronic cigarettes and any
tobacco product among middle and high school students—United
States, 2011–2018. MMWR Morb Mortal Wkly Rep 67: 1276–1277,
2018. doi:10.15585/mmwr.mm6745a5.
11. Cullen KA, Gentzke AS, Sawdey MD, Chang JT, Anic GM, Wang
TW, Creamer MR, Jamal A, Ambrose BK, King BA. e-Cigarette use
among youth in the United States, 2019. JAMA 322: 2095, 2019.
doi:10.1001/jama.2019.18387.
12. Huang J, Duan Z, Kwok J, Binns S, Vera LE, Kim Y, Szczypka G,
Emery SL. Vaping versus JUULing: how the extraordinary growth
and marketing of JUUL transformed the US retail e-cigarette market.
Tob Control28: 146–151, 2019. doi:10.1136/tobaccocontrol-2018-
054382.
13. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A,
Kurek J, Prokopowicz A, Jablonska-Czapla M, Rosik-Dulewska C,
Havel C, Jacob P, Benowitz N. Levels of selected carcinogens and
toxicants in vapour from electronic cigarettes. Tob Control 23: 133–
139, 2014. doi:10.1136/tobaccocontrol-2012-050859.
14. Moheimani RS, Bhetraratana M, Peters KM, Yang BK, Yin F,
Gornbein J, Araujo JA, Middlekauff HR. Sympathomimetic effects
of acute e-cigarette use: role of nicotine and non-nicotine constitu-
ents. J Am Heart Assoc 6: e006579, 2017. doi:10.1161/JAHA.117.
006579.
15. Cooke WH, Pokhrel A, Dowling C, Fogt DL, Rickards CA. Acute in-
halation of vaporized nicotine increases arterial pressure in young
non-smokers: a pilot study. Clin Auton Res 25: 267–270, 2015.
doi:10.1007/s10286-015-0304-z.
16. Garcia PD, Gornbein JA, Middlekauff HR. Cardiovascular auto-
nomic effects of electronic cigarette use: a systematic review.
Clin Auton Res, 30: 507–513, 2020. doi:10.1007/s10286-020-
00683-4.
17. Narkiewicz K, van de Borne PJ, Hausberg M, Cooley RL, Winniford
MD, Davison DE, Somers VK. Cigarette smoking increases sympa-
thetic outflow in humans. Circulation 98: 528–534, 1998. doi:10.1161/
01.CIR.98.6.528.
18. Bramer SL, Kallungal BA. Clinical considerations in study designs
that use cotinine as a biomarker. Biomarkers 8: 187–203, 2003.
doi:10.1080/13547500310012545.
19. Niedermaier ON, Smith ML, Beightol LA, Zukowska-Grojec Z,
Goldstein DS, Eckberg DL. Influence of cigarette smoking on human
autonomic function. Circulation 88: 562–571, 1993. doi:10.1161/01.
CIR.88.2.562.
20. Shinozaki N, Yuasa T, Takata S. Cigarette smoking augments sym-
pathetic nerve activity in patients with coronary heart disease. Int
Heart J 49: 261–272, 2008. doi:10.1536/ihj.49.261.
21. Gerhardt U, Vorneweg P, Riedasch M, Hohage H. Acute and per-
sistent effects of smoking on the baroreceptor function. J Auton
Pharmacol 19: 105–108, 1999. doi:10.1046/j.1365-2680.1999.
00123.x.
22. Lucini D, Bertocchi F, Malliani A, Pagani M. A controlled study of
the autonomic changes produced by habitual cigarette smoking in
healthy subjects. Cardiovasc Res 31: 633–639, 1996. doi:10.1016/
0008-6363(96)00013-2. doi:10.1016/S0008-6363(96)00013-2.
23. Mancia G, Groppelli A, Di Rienzo M, Castiglioni P, Parati G.
Smoking impairs baroreflex sensitivity in humans. Am J Physiol 273:
H1555–1560, 1997. doi:10.1152/ajpheart.1997.273.3.H1555.
24. Haass M, K€ ubler W. Nicotine and sympathetic neurotransmission.
Cardiovasc Drug Ther 10: 657–665, 1997. doi:10.1007/BF00053022.
25. Middlekauff HR, Park J, Moheimani RS. Adverse effects of cigarette
and noncigarette smoke exposure on the autonomic nervous sys-
tem: mechanisms and implications for cardiovascular risk. J Am Coll
Cardiol 64: 1740–1750, 2014. doi:10.1016/j.jacc.2014.06.1201.
26. Pope CA III, Burnett RT, Krewski D, Jerrett M, Shi Y, Calle EE, Mj T.
Cardiovascular mortality and exposure to airborne fine particulate mat-
ter and cigarette smoke: shape of the exposure-response relationship.
 AEROSOLIZED NICOTINE AND CARDIOVASCULAR CONTROL
Circulation 120: 941–948, 2009. doi:10.1161/CIRCULATIONAHA.109.
857888.
27. Eckberg DL. Sympathovagal balance: a critical appraisal. Circulation
96: 3224–3232, 1997. doi:10.1161/01.CIR.96.9.3224.
28. Malliani A, Pagani M, Lombardi F, Cerutti S. Cardiovascular neural
regulation explored in the frequency domain. Circulation 84: 482–
492, 1991. doi:10.1161/01.CIR.84.2.482.
29. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J,
Walker N. Electronic cigarettes for smoking cessation: a randomised
controlled trial. Lancet 382: 1629–1637, 2013. doi:10.1016/S0140-
6736(13)61842-5.
30. Hajek P, Corbin L, Ladmore D, Spearing E. Adding e-cigarettes to
specialist stop-smoking treatment: City of London pilot project. J
Addict Res Ther 6: 244, 2015. doi:10.4172/2155-6105.1000244.
31. Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal
N, Li J, Parrott S, Sasieni P, Dawkins L, Ross L, Goniewicz M, Wu Q,
McRobbie HJ. A randomized trial of e-cigarettes versus nicotine-
replacement therapy. N Engl J Med 380: 629–637, 2019. doi:10.
1056/NEJMoa1808779.
32. Farsalinos KE, Spyrou A, Stefopoulos C, Tsimopoulou K, Kourkoveli
P, Tsiapras D, Kyrzopoulos S, Poulas K, Voudris V. Nicotine absorp-
tion from electronic cigarette use: comparison between experienced
consumers (vapers) and naive users (smokers). Sci Rep 5: 11269, 2015
[Erratum in Sci Rep. 5:13506, 2015].doi:10.1038/srep11269.
AJP-Heart Circ Physiol  doi:10.1152/ajpheart.00448.2020  www.ajpheart.org
Downloaded from journals.physiology.org/journal/ajpheart (114.122.040.183) on March 26, 2024.
33. Hajek P, Goniewicz ML, Phillips A, Myers Smith K, West O,
McRobbie H. Nicotine intake from electronic cigarettes on initial use
and after 4 weeks of regular use. Nicotine Tob Res 17: 175–179,
2015. doi:10.1093/ntr/ntu153.
34. Lee YH, Gawron M, Goniewicz ML. Changes in puffing behavior
among smokers who switched from tobacco to electronic cigarettes.
Addict Behav 48: 1–4, 2015. doi:10.1016/j.addbeh.2015.04.003.
35. Hajek P, Pittaccio K, Pesola F, Myers Smith K, Phillips-Waller A,
Przulj D. Nicotine delivery and users’ reactions to JUUL compared
with cigarettes and other e-cigarette products. Addiction 115: 1141–
1148, 2020. doi:10.1111/add.14936.
36. Goniewicz ML, Boykan R, Messina CR, Eliscu A, Tolentino J. High
exposure to nicotine among adolescents who use Juul and other
vape pod systems (‘pods’). Tob Control 28: 676–677, 2019.
doi:10.1136/tobaccocontrol-2018-054565.
37. Pankow JF, Kim K, McWhirter KJ, Luo W, Escobedo JO, Strongin
RM, Duell AK, Peyton DH. Benzene formation in electronic cigarettes.
PLoS One 12: e0173055, 2017. doi:10.1371/journal.pone.0173055.
38. Talih S, Salman R, El-Hage R, Karam E, Karaoghlanian N, El-Hellani
A, Saliba N, Shihadeh A. Characteristics and toxicant emissions of
JUUL electronic cigarettes. Tob Control 28: 678–680, 2019.
doi:10.1136/tobaccocontrol-2018-054616.
39. Salzman GA, Alqawasma M, Asad H. Vaping associated lung injury
(EVALI): an explosive United States epidemic. J MO State Med
Assoc 116: 492–496, 2019.
H255