Long-Term Cardiopulmonary Outcomes and Quality of Life: A Comparative Study Among Cigarette, Electronic Cigarette and Dual use Consumers.

Long-Term Cardiopulmonary Outcomes and Quality of Life: A Comparative Study Among Cigarette, Electronic Cigarette and Dual use Consumers. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-Term Cardiopulmonary Outcomes and Quality of Life: A Comparative Study Among Cigarette, Electronic Cigarette and Dual use Consumers. Gokul Krishna, Ann Mary Jose, Weaam Rahali, Wejdan Alyamani, Manahel Mohammed, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4200243/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jan, 2026 Read the published version in Frontiers in Public Health → Version 1 posted You are reading this latest preprint version Abstract Background : Smoking is a leading cause of heart and lung diseases worldwide. Though there is a decline in tobacco smoking the use of e-cigarettes is growing in popularity. Objective: To assess the long-term effects of smoking, vaping, and dual use on cardiopulmonary function capacity and quality of life. Methods: The study participants were classified into five groups: Control, Individuals who use cigarettes only, Individuals who only use e-cigarettes, Individuals who previously smoked and currently use only e-cigarettes and Individuals who use both cigarettes and e-cigarettes. Participants performed PFT, 6MWT and completed HRQoL questionnaire. Results: A total of 175(85.7% male) participants with an average age of mean(±SD)27.38(±5.75) enrolled in the study. PFT results showed significant difference in FEV 1 (L/Sec) [F (4,170) = 7.73, p≤ 0.001] η²=0.15; FEV 1 (%predicted) [F (4,170) =24.63, p≤0.001] η²=0.36; and FEV 1 /FVC (%) [F (4,170) =16.85, p≤0.001] η² = 0.28 values across the five groups. On further analysis, FEV 1 and FEV 1 (%predicted) significantly decreased in all user groups. Similarly, in FEV 1 /FVC (%) significant difference was observed with user groups except those who only use e-cigarettes. 6MWT showed a significant difference in walking distance [F (4,170) = 19.93, p≤0.001] η² =0.31. HRQoL reported a significant difference in physical function [H (4) =20.55, p≤0.001], emotional well-being [H (4) =19.21, p=0.001], and social function [H (4) =29.63, p≤0.001] domains. Individuals who use both cigarettes and e-cigarettes reported a significant decline in lung function [(FEV 1 2.96±0.41, FEV 1 (% predicted) 72.6±6.07 and FEV 1 /FVC (%) 73.65±11], 6MWT walking distance(m) (mean ±SD) 416.26±53.49. Conclusion: We observed a significant long-term impairment in lung function, cardiopulmonary capacity, and quality of life among individuals who use cigarettes and e-cigarettes compared to those who never smoked or vaped. Also, individuals who use both cigarettes and e-cigarettes showed the worst health outcomes. electronic cigarettes cigarette smoking e-cigarettes smoking tobacco respiratory dual use Figures Figure 1 Figure 2 Figure 3 What is already known on this topic Globally, smoking stands as a primary contributor to heart and lung diseases, despite a decrease in tobacco use. Concurrently, the popularity of e-cigarettes, particularly among young adults, is on the rise. While vaping is often considered a tool for smoking cessation, a notable portion of those who adopt vaping to quit smoking still engage in both practices. The combined effects of vaping and smoking remain largely unexplored and warrant further study. What this study adds on The findings of the study indicate a decline in lung function measures, exercise capacity, and overall quality of life among individuals who have a long-term history of smoking cigarettes and/or using e-cigarettes compared to those who have never smoked or vaped. Furthermore, those who concurrently used both cigarettes and e-cigarettes showed poorer lung function, reduced exercise capacity, and lower quality of life compared to non-users and individual usage of cigarette or e-cigarette only. How this study might affect research, practice, or policy The research highlights the necessity for personalized clinical interventions to tackle the health risks linked to prolonged use of both cigarettes and e-cigarettes. From a policy perspective, comprehensive regulations are essential to curb observed health decrements, emphasizing the importance of targeted public health campaigns. Efforts should be directed towards deterring dual usage and implementing measures to restrict access and control marketing of both combustible and electronic tobacco products to safeguard the overall health of the population. Introduction Tobacco smoking is a worldwide problem, which is directly linked to chronic obstructive pulmonary disease (COPD), cancer, and cardiovascular disease (1). According to the World Health Organization (WHO), approximately 1.3 billion current people who smoke tobacco exist globally, out of which one person loses their life every 6 sec due to smoking-associated illnesses (2). Whereas electronic cigarettes (e-cigarettes) have been a relatively new product in the market since 2003 (3). E-cigarettes are battery-operated aerosol generators which heat a nicotine-containing solution (e-liquids) compared to burning tobacco such as in conventional cigarette smoking. These e-liquids contain various chemical elements including glycerol or propylene glycol, varying amounts of nicotine and flavors such as aldehydes, pyrazines, menthol, menthone, and other minty compounds, the practice of using e-cigarettes is commonly known as vaping (4, 5). In recent years, the trend of cigarette smoking has dramatically fallen with countries such as the US reporting as low as 14% of the total population smoking conventional tobacco (6). On the other hand, a steady increase in the prevalence of vaping among all age groups including high school students was reported globally (7-12). Due to its wrongful promotion as a safer alternative to tobacco products in the media, the availability of a variety of flavors and more socially acceptable than smoking led to the increased popularity of vaping (13). Even though the current evidence suggests vaping is less harmful than conventional tobacco smoking in the short term, chronic exposure to their residual toxicological load poses a risk to lung health and further studies are warranted (8, 14). Those who smoke cigarettes often use vaping as an aid for smoking cessation. Out of 3.6 million people (about twice the population of Nebraska) currently use e-cigarettes in the UK, it is estimated that 54.1% used cigarettes previously (15). Similarly, a US study reported approximately 22% of people who currently use e-cigarette, used to smoke cigarettes previously (<1 year) and 16% uses both cigarettes and e-cigarettes (7). Even though some individuals quit smoking with vaping, a substantial subset of the population continues to use both. The synergistic dual use effects of vaping and smoking are largely unknown and yet to be studied (16). We therefore prospectively investigated the long-term effects of smoking, vaping, and dual use in cardiopulmonary functions, capacity and quality of life compared to those who have never smoked or vaped. Also, we examined the health outcomes of individuals who used both cigarettes and e-cigarettes compared to those who only used either cigarettes or e-cigarettes. Methods Participants and assessment We conducted a cross-sectional study, subjects were enrolled into five groups based on cigarette and e-cigarette use, demographic information and medical history were collected and followed by pulmonary function testing (PFT) , a six-minute walk test (6MWT) and a completed Health-Related Quality of Life (HRQoL) questionnaire. Participants were recruited via the college website and social media platforms ( www.bmc.edu.sa ). The study was conducted over a period of one year and seven months from February 2023 to August 2023 at the PFT lab, Respiratory Therapy department, Batterjee Medical College (BMC), Jeddah, Saudi Arabia. Study protocol. The recruitment process for participants in our research on adult users (≥18 years old) incorporated a multi-faceted approach that utilized a variety of channels to reach potential participants. This included the use of online platforms such as Twitter, Facebook, and Snapchat, where visual advertisements and tailored messages were employed to highlight the study's objectives, eligibility criteria, and contact information. Moreover, flyers and visually appealing advertisements were strategically placed in vape shops to target regular customers outlining the study's purpose and providing clear instructions for participation. The participants were allocated into five groups. 1- Control, 2-Individuals who use cigarettes only, 3-Individuals who only use e-cigarettes, 4-Individuals who previously smoked and currently use only e-cigarettes and 5-Individuals who use both cigarettes and e-cigarettes. 1-The control group included participants who had never smoked or vaped. 2-Individuals who use cigarettes only had a history of smoking for at least 3.5 pack years or above and smoked only cigarettes based on previously conducted study (17). 3- E-cigarette use-only group participants were required to have a history of vaping for at least 3.5 years and above. 4- The previously smoked and currently uses e-cigarette group includes participants who report no smoking for the past year and a history of vaping for at least 3.5 years and above. 5- Use of both cigarette and e-cigarette group, participants had smoked for 3.5 years and had vaped for at least 3.5 years. Subjects with a history of unstable cardiopulmonary status, neuromuscular disorders, and diagnosed with any acute or chronic respiratory conditions, use of any respiratory medications such as corticosteroids were excluded.The tests were conducted in the same building and a 30-minute rest period was given between the tests. The BMC college clinic doctor was readily available for any emergencies during conducting the study. Pulmonary function test All participants performed spirometry. The measurements included forced vital capacity (FVC), forced expiratory volume in the first second (FEV 1 ), and FEV 1 / FVC were recorded. Absolute values and a percentage of expected normal values (% predicted) were used to express all PFT measurements. The test was carried out by the recommendations of the European Respiratory Society (ERS) and the American Thoracic Society (ATS) (18). The PFT machine was performed using Master Screen PFT powered by Sentry Suite (SentrySuite™ Software Solution | Vyaire Medical) Six-minute walk test For assessing the cardiopulmonary capacity, 6MWT was performed over a 30-meter indoor corridor with pre-and post-test measurements of oxygen saturation, blood pressure, fatigue, and dyspnea score assessed using a Borg Scale. The test was performed per ATS guidelines (19). Health-related quality of life The HRQoL domain was assessed using the RAND SF-36 questionnaire (20). It includes 36 items covering eight domains. Physical functioning (10 items), social functioning (2 items), role limitation due to physical health problems (4 items), role limitation due to emotional problems (4 items), bodily pain (2 items), emotional well-being (5 items), general health perceptions (5 items), and energy/fatigue (4 items). A higher score indicated a healthier state, with scores for each domain ranging from zero (worst) to 100 (best). Sample size: A priori power analysis was conducted using G*Power version 3.1.9.7 (21). To achieve 80% power for detecting a medium effect, at a significance criterion of α=0.05, the estimated sample size was n = 200 (one-way ANOVA test). Our post hoc G*Power analysis based on our study mean and SD of FEV1 with an effect size of 0.24, sample size of n=175, type-I errors (alpha) of 0.05 (5%), produced a power of 74%. Ethical approval The study was approved by the institutional ethical committee at BMC (RES 2023-0036). The purpose of the study was explained to all participants and informed consent was taken. Statistical analysis The test of normality was performed using the Shapiro–Wilkins test. Normally distributed data were represented as mean (± standard deviation (SD)) and non-normally distributed data as median (and interquartile range (IQR)). Categorical variables were expressed in number (and percentage (%)). One-way ANOVA and Kruskal-Wallis tests were used to compare the differences in continuous variables across the groups. A post-hoc Fisher’s least significant difference was applied to each significant ANOVA to determine the difference between the groups. The level of significance assumed was a p-value of ≤0.05. The results were analyzed using the Statistical Package for Social Sciences (SPSS version 25.0 for Windows, Chicago, IL USA) Results A total of 175 (85.7% males) participants with average age of (mean ±SD) 27.38± 5.75 were enrolled in the study. There was no significant difference in demographic data among the groups (Table 1). Table 1 Socio-Demographic data Parameters Control (n=35) Cigarette use only (n=35) E-cigarette use only (n=35) Previously smoked currently use e-cigarettes (n=35) Use of both cigarette and e-cigarette. (n=35) p value Gender (M/F) 26/9 32/3 27/8 33/2 32/3 - Age (years) Median (IQR) 25(7) 27(8) 25(4) 26(4) 26(4) 0.11 BMI Kg/m 2 Median (IQR) 23.91(3.71) 25.15(8.2) 23.3(7.39) 24.3(5.31) 23.87(5.25) 0.96 Heart Rate baseline (beats/min) (Mean ± SD) 86.22±13.75 84.91±13.58 85.62±14.61 85.57±16.74 86.68±15.76 0.49 Systolic Blood pressure (mmHg) (Mean ± SD) 132.8±13.75 128.94±16.96 130.51±15.5 131.6±13.07 131.91±12.27 0.36 Diastolic blood pressure (mmHg) (Mean ± SD) 78.57±10.66 76.42±13.22 77.6±11.07 79.88±10.4 76.14±9.18 0.29 Number of cigarettes per day Median (IQR) N/A 20(10) N/A 18(10) 20(10) - Smoking or vaping duration in years Median (IQR) N/A 5(6) 5(1) 4(1) 4(1) - Pulmonary function test The ANOVA test showed a significant difference in FEV 1 (L/sec), FEV 1 (% predicted) and FEV 1 /FVC (%) among the five groups) Table 2). The FEV 1 (L/sec) F (4,170) = 7.73, p ≤ 0.001, η²=0.15; FEV 1 (% predicted) F (4,170) = 24.63, p ≤ 0.001, η² = 0.36 and FEV1/FVC (%) F (4,170) = 16.85, p ≤ 0.001, η² = 0.28. Post-HOC analysis was conducted to identify the difference between the group in FEV 1 (L/sec), control vs cigarette use only 0.47 (95% CI 0·19–0·74; p=0·001), control vs e-cigarette use only 0.41(95% CI 0·14–0·60; p=0·01), control vs previously smoked currently use e-cigarettes 0.41 (95% CI 0·14–0·74; p=0·02) and control vs use of both cigarette and e-cigarette 0.75 (95% CI 0·48–1.03; p ≤ 0.001) were significant (Fig.1A). Also, use of both cigarette and e-cigarettes had significant differences in FEV 1 between all other user groups (Fig.1B-D). Use of both cigarette and e-cigarette vs cigarette use only 0.33 (95% CI 0·62–0·04; p=0·016) (Fig.1B), Use of both cigarette and e-cigarette vs e-cigarette use only 0.34 (95% CI 0.61–0·06; p=0·01) (Fig.1C), Use of both cigarette and e-cigarette vs previously smoked currently use e-cigarettes 0.42 (95% CI 0·69–0·14; p=0·001) (Fig.1D). Table 2 Pulmonary function test Parameters Control (n=35) Cigarette use only (n=35) E-cigarette use only (n=35) Previously smoked currently use e-cigarettes. (n=35) Use of both Cigarette and e-cigarette. (n=35) p value FEV 1 (L/Sec) 3.72±0.63 3.25±0.55 3.30±0.69 3.38±0.57 2.96±0.41 ≤ 0.001 FEV 1 (% predicted) 96.65±11.87 79.40±11.94 81.45±9.74 83.08±11.58 72.6±6.07 ≤ 0.001 FVC (L) 4.23±0.75 4.11±0.72 4.06±0.94 4.38±0.67 4.11±0.76 0.425 FVC (% predicted) 92.28±18.4 84.2±12.54 87.91±12.7 84.81±23.34 84.28±11.18 0.179 FEV 1 /FVC (%) 90.39±6.78 79.71±9.73 91.23±11.2 80.37±17 73.65±11 ≤ 0.001 Note: Values are presented as Mean ± SD The exploratory analysis in FEV 1 /FVC (%) value showed control vs. cigarette use only 10.68 (95% CI 5.55–15.8; p ≤ 0.001), control vs previously smoked currently use e-cigarettes 10.02 (95% CI 4.89–15.15; p ≤ 0.001) and control vs use of both cigarette and e-cigarette 16.73(95% CI 11.61–21.86; p ≤ 0.001) (Fig. 2A). Use of both cigarette and e-cigarette vs cigarette use only 6.05 (95% CI 0.92–11.18; p = 0.001) (Fig. 2B), Use of both cigarette and e-cigarette vs e-cigarette use only 17.57 (95% CI 12.44–22.7; p ≤ 0.001) (Fig. 2C) and Use of both cigarette and e-cigarette vs previously smoked currently use e-cigarettes 6.71 (95% CI 11.84–1.58; p = 0.03) (Fig. 2D). Also, cigarette use only vs e-cigarette use only 11.51 (95% CI 16.64–6.39; p ≤ 0.001), e-cigarette use only vs previously smoked currently use e-cigarettes 10.86 (95% CI 5.73–15.98; p ≤ 0.001) were significant. Six Minute walk test The 6MWT showed a significant difference in walking distance across the groups F (4,170) = 19.93, p ≤ 0.001, η² = 0.31. The statistical test showed a significant reduction among the control vs other groups in walked distance (Table 3). Further analysis showed a significant reduction between the control vs all groups who smoke within walking distance. Control vs cigarette use only 99.82 (95% CI 66.05–133.59; p ≤ 0.001), control vs e-cigarette use only 76.28 (95% CI 42.51–110.05; p ≤ 0.001), control vs previously smoked currently use e-cigarettes 100.23 (95% CI 66.46–133.99; p ≤ 0.001) control vs use of both cigarette and e-cigarette147.55 (95% CI 113.78–181.32; p ≤ 0.001) (Fig.3A). Similarly, significant differences were observed between the use of both cigarette and e-cigarettes and other user groups. Use of both cigarette and e-cigarette vs cigarette use only 47.72 (95% CI 81.49–13.95; p = 0.001) (Fig.3B), Use of both cigarette and e-cigarette vs e-cigarette use only 71.27 (95% CI 105.03–37.50; p ≤ 0.001) (Fig.3C), and use of both cigarette and e-cigarette vs previously smoked currently use e-cigarettes 47.32 (95% CI 81.09-13.55; p = 0.004) (Fig.3D). Table 3 Six Minute walk test 6MWT Control (n=35) Cigarette use only (n=35) E-cigarette use only (n=35) Previously smoked currently use e-cigarettes (n=35) Use of both cigarette and e-cigarette. (n=35) p value Walked Distance (m) 564.42±92.95 464.59± 59.33 488.13± 68.22 464.19± 76.96 416.26±53.49 ≤ 0.001 Post 6MWT Dyspnea Score 0 0 0 0 0 0.31 Post 6MWT SPO2 99.28±1.4 99.2±1.18 99.11±1.74 99.37±0.8 99.2±0.83 0.55 Note: Values are presented as Mean ± SD Health-related quality of life (HRQoL) The SF-36 questionnaire indicated a significant reduction in three domains physical function H= (4) 20.55, p ≤ 0.001, emotional well-being H (4)= 19.21, p =0.001 and social function H (4) = 29.63, p ≤ 0.001. Further exploratory analysis in the physical function domain showed a significant difference between control vs cigarette use only (p=0.03), control vs e-cigarette use only (p=0.04) and control vs use of both cigarette and e-cigarette (p ≤ 0.001). In the emotional well-being domain control vs cigarette use only (p=0.04), control vs previously smoked currently use e-cigarettes (p=0.004) and control vs use of both cigarette and e-cigarette (p = 0.003) were significantly different. In the social function domain use of both cigarette and e-cigarette vs control (p≤ 0.001), use of both cigarette and e-cigarette vs cigarette use only (p=0.01), use of both cigarette and e-cigarette vs e-cigarette use only (p=0.003) and use of both cigarette and e-cigarettevs previously smoked currently use e-cigarettes (p=0.004) were significant. (Table 4) represents the comparison of HRQoL between the groups. Table 4 Health Related Quality of Life SF-36 Control (n=35) Cigarette use only (n=35) E-cigarette use only (n=35) Previously smoked currently use e-cigarettes (n=35) Use of both cigarette and e-cigarette. (n=35) p value Physical functioning 100(10) 85(20) 90(20) 90(15) 90(10) ≤ 0.001 Role limitations due to physical health 100(15) 100(25) 95(25) 100(25) 90(25) 0.47 Role limitation due to emotional problem 90(20) 100(30) 95(30) 90(30) 80(30) 0.74 Energy fatigue 80(15) 80(25) 80(20) 75(15) 80(13.5) 0.17 Emotional well-being 90(20) 80(20) 80(15) 80(17) 76(18) 0.001 Social function 90(20) 87.5 (31.5) 80(25) 87.5(30) 75(17.50) ≤ 0.001 Pain 90(20) 90(22.50) 100(20) 87.5(22.5) 80.5(20) 0.186 General Health 85(10) 80(15) 80(25) 80(20) 80(20) 0.162 Health change 80(25) 75(35) 80(10) 75(30) 75(10) 0.300 Note: Values are presented as Median (IQR) Discussion This study shows a decline in lung function parameters, exercise capacity, and quality of life in individuals who use cigarettes and e-cigarettes for the long term compared to individuals who never smoked or vaped. Furthermore, worse lung function status, exercise capacity, and quality of life were observed among those who used both cigarettes and e-cigarettes. The reduction in lung function associated with both short and long-term use of cigarette smoking is well established (22). However, evidence regarding the health outcomes of vaping and dual use is still emerging and its long-term cardiopulmonary effects are largely unknown (23). The lung function studies reported in vaping are primarily of short-term usage, while the current study reports the characteristics of long-term users (3.5 years or more). A reduction in lung function parameters such as in FEV 1 , mid-expiratory flow rates FEV1/FVC ratio and DLCO were reported by Meo et al and Antoneiwich et al (24, 25). Whereas other similar studies reported no changes in the FEV 1 or FEV 1 /FVC ratio in those who used e-cigarettes for short-term (26, 27). The present study observed a significant reduction in FEV1 and walked distance among those who only used e-cigarettes compared to those who never smoked or vaped. Contrary to our findings, Polosa et al long-term follow-up study of individuals who use e-cigarettes reported no significant difference in lung function, respiratory symptoms and lung imaging compared to never users (28). The variations in the study characteristics, such as the duration of vape (median (IQR) 5 (1) years and median (range) 8 (3.5 -15) months in their study) and sample size (135 vs 21) are the possible rationale for the differences in the outcomes. Interestingly, no previous studies reported long-term changes in lung function among individuals who use both cigarettes and e-cigarettes, while current study findings point out a significant decline in lung function such as FEV 1 (L/sec) and FEV 1 /FVC (%) among those who used both cigarette and e-cigarettes. The inhalation of nicotine and other chemicals in both cigarettes and e-cigarettes impairs the oxygen uptake and its utilization by the body leading to a decline in exercise capacity (29-32). In the current study, compared to those who never smoked or vaped all the user groups had a significant reduction in walked distance with individuals who use both cigarettes and e-cigarettes being affected the most. Similarly, Dinkelo et al reported the physical training and fitness among people who smoke cigarettes and e-cigarettes. In their study, overall physical training was highest among never users, followed by individuals who vaped, smoked, and those who used both (33). The reduction in lung function, exercise capacity, and respiratory symptoms among people who use cigarettes and e-cigarettes impede the ability to participate in daily activities and ultimately impact overall well-being and quality of life (34, 35). In our study, there was a significant reduction in the physical function domain which includes limitations in performing moderate to vigorous daily activities was observed among participants who use cigarettes and e-cigarettes. Furthermore, a significant decline in emotional well-being and social function domains was also observed in the smoking groups which is consistent with the existing evidence linking mental health comorbidities with smoking and vaping (36, 37). Interestingly, the use of both cigarettes and e-cigarettes reported worse scores in emotional well-being and social function compared to other types of users. Similar to our study findings, the use of both cigarettes and e-cigarettes was previously reported to have a worse SF-12 general health score and breathing difficulty score compared to people who smoke cigarettes only (16). People who use both cigarette and e-cigarettes reportedly initiate e-cigarettes as a safer alternative for nicotine delivery and to quit smoking (38). However, people who use e-cigarettes end up using both possibly due to either higher nicotine dependence or dissatisfaction with lower levels of nicotine in the vape (39-41). In our study lung function parameters, such as FEV 1 (L/sec) among those who used both cigarettes and e-cigarettes showed a difference of 20.43% compared to control, 8.92% compared to those who used cigarettes only, 10.30% compared to those who used e-cigarettes only and 12.42% compared to those who previously smoked currently use e-cigarettes. Similarly, FEV 1 /FVC (%) showed a difference of 18.51% compared to control, 7.60% compared to those who used cigarettes only, 19.3% compared to those who use e-cigarettes only and 8.4% compared to individuals who previously smoked and currently use e-cigarettes compared to those who use both cigarette and e-cigarettes respectively. Also, no previous studies reported long-term changes in lung function among individuals who use both cigarettes and e-cigarettes, making this study one of its kind. However, the decline in cardiopulmonary fitness and quality of life among those who use both cigarettes and e-cigarettes aligned with previous study findings (16, 33). Our study limitations include a low number of female participants, and not measuring the inflammatory biomarkers and oxidative stress markers which would have provided further information on systemic effects of cigarettes and e-cigarettes. Also, in the Middle East hookah (waterpipe) smoking is a common practice and we have not included them in the study. Future research focusing on the biomarkers of e-cigarette-related inflammatory and oxidative stress outcomes may yield more insightful findings for evaluating the long-term health implications of vape and dual usage. Conclusion The findings of this study demonstrate a significant long-term impairment in lung function, cardiopulmonary capacity, and quality of life among people who smoke cigarettes and e-cigarettes compared to those who never smoked or vaped. Also, individuals who use both cigarettes and e-cigarettes showed worse health outcomes compared to those who never smoked or only used either cigarettes or e-cigarettes. Declarations Ethics approval and consent to participate : Institutional Ethical approval was obtained, and consent form was obtained from every participant. The links to access the ethical approval and format of the participant consent form used are shared below. Appendix 1 Ethical approval - Long-Term Cardiopulmonary Outcomes and Quality of Life A Comparative Study Among Cigarette, Electronic Cigarette and dual use.PDF Appendix 2 Consumer consent to participate - Long-Term Cardiopulmonary Outcomes and Quality of Life A Comparative Study Among Cigarette, Electronic Cigarette and dual use.pdf Consent for publication: We had adhered to relevant data protection laws and regulations to safeguard the privacy of research participants by adapting anonymization by removing any identifying information / media from the published data or results to prevent individuals from being identifiable and using pseudonyms or codes instead of using their real names to protect their identities or any other details. Participants are also explained about the presenting/publishing the scientific details of the study upon completion of the research. Availability of data and materials: The data set for this research can be assessed through he below link: Appendix 3 Data and Materials - Long-Term Cardiopulmonary Outcomes and Quality of Life A Comparative Study Among Cigarette, Electronic Cigarette and dual use.xlsx Competing interests: The authors declare no competing interests. Funding : The authors received no specific funding for this work. Authors' contributions: Author name Contribution Gokul G. Krishna Conception, Design of work, Draft the work Ann Mary Jose Design of work, Draft the work Weaam A. Rahali Design of work, Draft the work Wejdan W. Alyamani The acquisition, analysis Manahel A Mohammed The acquisition, analysis Basmah S. Alghamdi The acquisition, analysis Mazen M. Homoud Substantively revised it Mohammed D. Al-Ahmari Substantively revised it Saleh R. Alkhathami Substantively revised it Jithin K. Sreedharan Substantively revised it Khalid S. Alwadeai Substantively revised it Ayedh D. 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Dinkeloo E, Grier TL, Brooks RD, Jones BH. Vaping, smoking, and the physical fitness of active young men. American Journal of Preventive Medicine. 2020;58(1):e31-e7. General USPHSOotS. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General: US Department of Health and Human Services, Public Health Service, Office of …; 2010. Wang MP, Ho SY, Leung LT, Lam TH. Electronic cigarette use and respiratory symptoms in Chinese adolescents in Hong Kong. JAMA pediatrics. 2016;170(1):89-91. Heiligenstein E, Smith SS. Smoking and Mental Health Problems in Treatment-Seeking University Students. Nicotine & Tobacco Research. 2006;8(4):519-23. Becker TD, Arnold MK, Ro V, Martin L, Rice TR. Systematic review of electronic cigarette use (vaping) and mental health comorbidity among adolescents and young adults. Nicotine and Tobacco Research. 2021;23(3):415-25. Pokhrel P, Herzog TA, Muranaka N, Regmi S, Fagan P. Contexts of cigarette and e-cigarette use among dual users: a qualitative study. BMC public health. 2015;15:1-9. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tobacco control. 2010;19(2):98-103. Vansickel AR, Cobb CO, Weaver MF, Eissenberg TE. A clinical laboratory model for evaluating the acute effects of electronic “cigarettes”: nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiology, Biomarkers & Prevention. 2010;19(8):1945-53. Benowitz NL, Donny EC, Hatsukami DK. Reduced nicotine content cigarettes, e-cigarettes and the cigarette end game. Addiction (Abingdon, England). 2017;112(1):6. Additional Declarations No competing interests reported. Supplementary Files LongTermCardiopulmonaryOutcomesandQualityofLifeAComparativeStudyAmongCigaretteElectronicCigaretteanddualuseConsumerstables.pdf Cite Share Download PDF Status: Published Journal Publication published 12 Jan, 2026 Read the published version in Frontiers in Public Health → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4200243","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":287792544,"identity":"81237016-4111-411b-b65d-36223ef6ef4c","order_by":0,"name":"Gokul Krishna","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Gokul","middleName":"","lastName":"Krishna","suffix":""},{"id":287792547,"identity":"9a81d15e-f8af-4273-b0c4-40164ee6f71f","order_by":1,"name":"Ann Mary Jose","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ann","middleName":"Mary","lastName":"Jose","suffix":""},{"id":287792549,"identity":"1368e159-8475-44cb-be54-5cb9384f19b0","order_by":2,"name":"Weaam Rahali","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Weaam","middleName":"","lastName":"Rahali","suffix":""},{"id":287792550,"identity":"d0697508-2c63-4cff-8bcc-5e665e29fc1f","order_by":3,"name":"Wejdan Alyamani","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Wejdan","middleName":"","lastName":"Alyamani","suffix":""},{"id":287792551,"identity":"3dc373c6-2e40-45c4-8aec-42b6bd2191a5","order_by":4,"name":"Manahel Mohammed","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Manahel","middleName":"","lastName":"Mohammed","suffix":""},{"id":287792552,"identity":"056be361-41de-42fa-9e65-9900cab9e900","order_by":5,"name":"Basmah Alghamdi","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Basmah","middleName":"","lastName":"Alghamdi","suffix":""},{"id":287792553,"identity":"82c064cc-4a1d-4b1e-8bdb-87ecd4b7cdc9","order_by":6,"name":"Mazen Homoud","email":"","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":false,"prefix":"","firstName":"Mazen","middleName":"","lastName":"Homoud","suffix":""},{"id":287792554,"identity":"80b4da18-4631-4551-9d3f-6dec5268bdb3","order_by":7,"name":"Mohammed AlAhmari","email":"","orcid":"","institution":"Dammam Medical Complex, Eastern Health 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University of Doha for Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Jithin","middleName":"","lastName":"Sreedharan","suffix":""},{"id":287792558,"identity":"8d2f63ee-91a7-44ad-8aeb-e51ed2506038","order_by":11,"name":"Ayedh Alahmari","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYJACaQYG5gQG5gMMDB8bwAIGRGphS2BgnEmyFmZeYrTwz0g+eLuAwTqPv4352GfbHdvkGdibt0kw/LHDqUXiRlqy9QyG9GKJY2zJs3PP3DZs4DlWJsHYlozbmhs5ZtI8DIcTG+73GDPntt1OYJDIMZNgbGDGqUP+Rv43sJb5x/g/M1uCtMi/MQM6rB6nFoMbOWxgLRuO8TAzM4Jt4QFqYTuMU4vhmWfG1jwG6Ykbj7EZM/YC/dLGk1Zskdh2HKcWuePJD2/zVFgnzjvG/Jjh547b8vzshzfe+PCnGrf3BRIYUCOCDUQk4NYAjJgD+GRHwSgYBaNgFAABAAqwUH74J5yvAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Respiratory Therapy, Batterjee Medical College","correspondingAuthor":true,"prefix":"","firstName":"Ayedh","middleName":"","lastName":"Alahmari","suffix":""}],"badges":[],"createdAt":"2024-04-01 11:16:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4200243/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4200243/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3389/fpubh.2025.1707230","type":"published","date":"2026-01-13T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54395250,"identity":"4c16b980-82d3-4a1b-bd44-cecf8305e9c7","added_by":"auto","created_at":"2024-04-09 21:20:58","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80735,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A-D) comparison of FEV1 (L/sec) between the groups\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4200243/v1/13ab258d0538a1bbc3d1a8a1.jpg"},{"id":54394615,"identity":"fbe2535e-11fc-4190-808d-ef96d5c3309e","added_by":"auto","created_at":"2024-04-09 21:12:59","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82212,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A-D) comparison of FEV1/FVC (%) between the groups\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4200243/v1/2b3f3bc78bfdfaa371079b85.jpg"},{"id":54394613,"identity":"932ac1e0-1328-4869-b67e-ac03379bc298","added_by":"auto","created_at":"2024-04-09 21:12:58","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":72438,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A-D) comparison of walked distance between the groups.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4200243/v1/44a3240bdc2ae98cf42ce5aa.jpg"},{"id":100718476,"identity":"e9b24d57-ad7a-4378-b4e2-90682eaccbb7","added_by":"auto","created_at":"2026-01-20 19:19:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":885755,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4200243/v1/27a9bb2a-ab35-434e-a939-e9bf8dca4d5b.pdf"},{"id":54394616,"identity":"6e31969c-75f5-422c-b1ea-a709b1750799","added_by":"auto","created_at":"2024-04-09 21:12:59","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":157023,"visible":true,"origin":"","legend":"","description":"","filename":"LongTermCardiopulmonaryOutcomesandQualityofLifeAComparativeStudyAmongCigaretteElectronicCigaretteanddualuseConsumerstables.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4200243/v1/67e703ded0b7818da921d417.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-Term Cardiopulmonary Outcomes and Quality of Life: A Comparative Study Among Cigarette, Electronic Cigarette and Dual use Consumers.","fulltext":[{"header":"What is already known on this topic ","content":"\u003cp\u003eGlobally, smoking stands as a primary contributor to heart and lung diseases, despite a decrease in tobacco use. Concurrently, the popularity of e-cigarettes, particularly among young adults, is on the rise. While vaping is often considered a tool for smoking cessation, a notable portion of those who adopt vaping to quit smoking still engage in both practices. The combined effects of vaping and smoking remain largely unexplored and warrant further study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds on\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings of the study indicate a decline in lung function measures, exercise capacity, and overall quality of life among individuals who have a long-term history of smoking cigarettes and/or using e-cigarettes compared to those who have never smoked or vaped. Furthermore, those who concurrently used both cigarettes and e-cigarettes showed poorer lung function, reduced exercise capacity, and lower quality of life compared to non-users and individual usage of cigarette or e-cigarette only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice, or policy\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe research highlights the necessity for personalized clinical interventions to tackle the health risks linked to prolonged use of both cigarettes and e-cigarettes. From a policy perspective, comprehensive regulations are essential to curb observed health decrements, emphasizing the importance of targeted public health campaigns. Efforts should be directed towards deterring dual usage and implementing measures to restrict access and control marketing of both combustible and electronic tobacco products to safeguard the overall health of the population.\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eTobacco smoking is a worldwide problem, which is directly linked to chronic obstructive pulmonary disease (COPD), cancer, and cardiovascular disease (1). According to the World Health Organization (WHO), approximately 1.3 billion current people who smoke tobacco exist globally, out of which one person loses their life every 6 sec due to smoking-associated illnesses (2). Whereas electronic cigarettes (e-cigarettes) have been a relatively new product in the market since 2003 (3). E-cigarettes are battery-operated aerosol generators which heat a nicotine-containing solution (e-liquids) compared to burning tobacco such as in conventional cigarette smoking. These e-liquids contain various chemical elements including glycerol or propylene glycol, varying amounts of nicotine and flavors such as aldehydes, pyrazines, menthol, menthone, and other minty compounds, the practice of using e-cigarettes is commonly known as vaping (4, 5).\u003c/p\u003e\n\u003cp\u003eIn recent years, the trend of cigarette smoking has dramatically fallen with countries such as the US reporting as low as 14% of the total population smoking conventional tobacco\u0026nbsp;(6). On the other hand, a steady increase in the prevalence of vaping among all age groups including high school students was\u003csub\u003e\u0026nbsp;\u003c/sub\u003ereported globally\u0026nbsp;(7-12). Due to its wrongful promotion as a safer alternative to tobacco products in the media, the availability of a variety of flavors and more socially acceptable than smoking led to the increased popularity of vaping (13). Even though the current evidence suggests vaping is less harmful than conventional tobacco smoking in the short term, chronic exposure to their residual toxicological load poses a risk to lung health and further studies are warranted (8, 14).\u003c/p\u003e\n\u003cp\u003eThose who smoke cigarettes often use vaping as an aid for smoking cessation. Out of 3.6 million people (about twice the population of Nebraska) currently use e-cigarettes in the UK, it is estimated that 54.1% used cigarettes previously (15). Similarly, a US study reported approximately 22% of people who currently use e-cigarette, used to smoke cigarettes previously (\u0026lt;1 year) and 16% uses both cigarettes and e-cigarettes (7). Even though some individuals quit smoking with vaping, a substantial subset of the population continues to use both. The synergistic dual use effects of vaping and smoking are largely unknown and yet to be studied (16).\u003c/p\u003e\n\u003cp\u003eWe therefore prospectively investigated the long-term effects of smoking, vaping, and dual use in cardiopulmonary functions, capacity and quality of life compared to those who have never smoked or vaped. Also, we examined the health outcomes of individuals who used both cigarettes and e-cigarettes compared to those who only used either cigarettes or e-cigarettes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eParticipants and assessment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a cross-sectional study, subjects were enrolled into five groups based on cigarette and e-cigarette use, demographic information and medical history were collected and followed by pulmonary function testing\u003cem\u003e\u0026nbsp;(PFT)\u003c/em\u003e, a six-minute walk test (6MWT) and a completed Health-Related Quality of Life (HRQoL) questionnaire. Participants were recruited via the college website and social media platforms\u003cem\u003e\u0026nbsp;(\u003c/em\u003ewww.bmc.edu.sa\u003cem\u003e).\u003c/em\u003e The study was conducted over a period of one year and seven months from February 2023 to August 2023 at the PFT lab, Respiratory Therapy department, Batterjee Medical College (BMC), Jeddah, Saudi Arabia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy protocol.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment process for participants in our research on adult users (\u0026ge;18 years old) incorporated a multi-faceted approach that utilized a variety of channels to reach potential participants. This included the use of online platforms such as Twitter, Facebook, and Snapchat, where visual advertisements and tailored messages were employed to highlight the study\u0026apos;s objectives, eligibility criteria, and contact information. Moreover, flyers and visually appealing advertisements were strategically placed in vape shops to target regular customers outlining the study\u0026apos;s purpose and providing clear instructions for participation.\u0026nbsp;The participants were allocated into five groups. 1- Control, 2-Individuals who use cigarettes only, 3-Individuals who only use e-cigarettes, 4-Individuals who previously smoked and currently use only e-cigarettes and 5-Individuals who use both cigarettes and e-cigarettes. 1-The control group included participants who had never smoked or vaped. 2-Individuals who use cigarettes only had a history of smoking for at least 3.5 pack years or above and smoked only cigarettes based on previously conducted study (17). 3- E-cigarette use-only group participants were required to have a history of vaping for at least 3.5 years and above. 4- The previously smoked and currently uses e-cigarette group includes participants who report no smoking for the past year and a history of vaping for at least 3.5 years and above. 5- Use of both cigarette and e-cigarette group, participants had smoked for 3.5 years and had vaped for at least 3.5 years.\u0026nbsp;Subjects with a history of unstable cardiopulmonary status, neuromuscular disorders, and diagnosed with any acute or chronic respiratory conditions, use of any respiratory medications such as corticosteroids were excluded.The tests were conducted in the same building and a 30-minute rest period was given between the tests. The \u003cem\u003eBMC\u0026nbsp;\u003c/em\u003ecollege clinic doctor was readily available for any emergencies during conducting the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePulmonary function test\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants performed spirometry.\u0026nbsp;The measurements included forced vital capacity (FVC), forced expiratory volume in the first second (FEV\u003csub\u003e1\u003c/sub\u003e), and FEV\u003csub\u003e1\u003c/sub\u003e / FVC were recorded. Absolute values and a percentage of expected normal values (% predicted) were used to express all PFT measurements. The test was carried out by the recommendations of the European Respiratory Society (ERS) and the American Thoracic Society (ATS)\u0026nbsp;(18). The PFT machine was performed using Master Screen PFT powered by Sentry Suite\u0026nbsp;(SentrySuite\u0026trade; Software Solution | Vyaire Medical)\u003c/p\u003e\n\u003cp\u003eSix-minute walk test\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor assessing the cardiopulmonary capacity, 6MWT was performed over a 30-meter indoor corridor with pre-and post-test measurements of oxygen saturation, blood pressure, fatigue, and dyspnea score assessed using a Borg Scale. The test was performed per ATS guidelines\u0026nbsp;(19).\u003c/p\u003e\n\u003cp\u003eHealth-related quality of life\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe HRQoL domain was assessed using the RAND SF-36 questionnaire\u0026nbsp;(20). It includes 36 items covering eight domains. Physical functioning (10 items), social functioning (2 items), role limitation due to physical health problems (4 items), role limitation due to emotional problems (4 items), bodily pain (2 items), emotional well-being (5 items), general health perceptions (5 items), and energy/fatigue (4 items). A higher score indicated a healthier state, with scores for each domain ranging from zero (worst) to 100 (best).\u003c/p\u003e\n\u003cp\u003eSample size:\u003c/p\u003e\n\u003cp\u003eA priori power analysis was conducted using G*Power version 3.1.9.7\u0026nbsp;(21). To achieve 80% power for detecting a medium effect, at a significance criterion of \u0026alpha;=0.05, the estimated sample size was \u003cem\u003en\u003c/em\u003e = 200 (one-way ANOVA test).\u0026nbsp;Our post hoc G*Power\u0026nbsp;analysis based on our study mean and SD of FEV1 with an effect size of 0.24, sample size of n=175, type-I errors (alpha) of 0.05 (5%), produced a power of 74%.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study\u0026nbsp;was approved by the institutional ethical committee at BMC (RES 2023-0036). The purpose of the study was explained to all participants and informed consent was taken.\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003eThe test of normality was performed using the Shapiro\u0026ndash;Wilkins test. Normally distributed data were represented as mean (\u0026plusmn; standard deviation (SD)) and non-normally distributed data as median (and interquartile range (IQR)). Categorical variables were expressed in number (and percentage (%)). One-way ANOVA and Kruskal-Wallis tests were used to compare the differences in continuous variables across the groups. A post-hoc Fisher\u0026rsquo;s least significant difference was applied to each significant ANOVA to determine the difference between the groups. The level of significance assumed was a p-value of \u0026le;0.05. The results were analyzed using the Statistical Package for Social Sciences (SPSS version 25.0 for Windows, Chicago, IL USA)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 175 (85.7% males) participants with average age of (mean \u0026plusmn;SD) 27.38\u0026plusmn; 5.75 were enrolled in the study. There was no significant difference in demographic data among the groups (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"687\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003e\u003cem\u003eTable 1 Socio-Demographic data\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003eControl (n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003eCigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003eE-cigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003ePreviously smoked currently use e-cigarettes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003eUse of both cigarette and \u0026nbsp; \u0026nbsp; \u0026nbsp;e-cigarette.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eGender (M/F)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003e26/9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e32/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e27/8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e33/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e32/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eAge (years) Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003e25(7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e27(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e25(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e26(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e26(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eBMI Kg/m\u003csup\u003e2\u003c/sup\u003e Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003e23.91(3.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e25.15(8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e23.3(7.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e24.3(5.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e23.87(5.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eHeart Rate baseline (beats/min)\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003e86.22\u0026plusmn;13.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e84.91\u0026plusmn;13.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e85.62\u0026plusmn;14.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e85.57\u0026plusmn;16.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e86.68\u0026plusmn;15.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eSystolic Blood pressure (mmHg)\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003e\u0026nbsp;132.8\u0026plusmn;13.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e128.94\u0026plusmn;16.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e130.51\u0026plusmn;15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e131.6\u0026plusmn;13.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e131.91\u0026plusmn;12.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eDiastolic blood pressure (mmHg)\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003e78.57\u0026plusmn;10.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e76.42\u0026plusmn;13.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e77.6\u0026plusmn;11.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e79.88\u0026plusmn;10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e76.14\u0026plusmn;9.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eNumber of cigarettes per day Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e20(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e18(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e20(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.922852983988356%\"\u003e\n \u003cp\u003eSmoking or vaping duration in years \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.847161572052402%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.55604075691412%\"\u003e\n \u003cp\u003e5(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e5(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.828238719068413%\"\u003e\n \u003cp\u003e4(1) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.720524017467248%\"\u003e\n \u003cp\u003e4(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.296943231441048%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003ePulmonary function test\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ANOVA test showed a significant difference in FEV\u003csub\u003e1\u003c/sub\u003e (L/sec), FEV\u003csub\u003e1\u003c/sub\u003e (% predicted) and FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%)\u0026nbsp;among the five groups) Table 2). The FEV\u003csub\u003e1\u003c/sub\u003e(L/sec) F (4,170) = 7.73, p \u0026le; 0.001,\u0026nbsp;\u003cem\u003e\u0026eta;\u0026sup2;=0.15;\u0026nbsp;\u003c/em\u003eFEV\u003csub\u003e1\u003c/sub\u003e (% predicted) F\u0026nbsp;(4,170) = 24.63, p \u0026le; 0.001,\u0026nbsp;\u003cem\u003e\u0026eta;\u0026sup2; = 0.36\u0026nbsp;\u003c/em\u003eand FEV1/FVC (%)\u0026nbsp;F (4,170) = 16.85, p \u0026le; 0.001,\u0026nbsp;\u003cem\u003e\u0026eta;\u0026sup2; = 0.28.\u003c/em\u003e Post-HOC analysis was conducted to identify the difference between the group in FEV\u003csub\u003e1\u0026nbsp;\u003c/sub\u003e(L/sec), \u0026nbsp;control vs cigarette use only 0.47 (95% CI 0\u0026middot;19\u0026ndash;0\u0026middot;74; p=0\u0026middot;001), control vs e-cigarette use only 0.41(95% CI 0\u0026middot;14\u0026ndash;0\u0026middot;60; p=0\u0026middot;01), control vs previously smoked currently use e-cigarettes 0.41 (95% CI 0\u0026middot;14\u0026ndash;0\u0026middot;74; p=0\u0026middot;02) and control vs use of both cigarette and e-cigarette 0.75 (95% CI 0\u0026middot;48\u0026ndash;1.03; p \u0026le; 0.001) were significant (Fig.1A). Also, use of both cigarette and e-cigarettes had significant differences in FEV\u003csub\u003e1\u003c/sub\u003e between all other user groups (Fig.1B-D). Use of \u0026nbsp;both cigarette and e-cigarette vs cigarette use only 0.33 (95% CI 0\u0026middot;62\u0026ndash;0\u0026middot;04; p=0\u0026middot;016) (Fig.1B), Use of both cigarette and e-cigarette vs e-cigarette use only 0.34 (95% CI 0.61\u0026ndash;0\u0026middot;06; p=0\u0026middot;01) (Fig.1C), Use of both cigarette and e-cigarette vs previously smoked currently use e-cigarettes 0.42 (95% CI 0\u0026middot;69\u0026ndash;0\u0026middot;14; p=0\u0026middot;001) (Fig.1D).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"679\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003eTable 2 Pulmonary function test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.88235294117647%\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.941176470588236%\"\u003e\n \u003cp\u003eControl (n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.735294117647058%\"\u003e\n \u003cp\u003eCigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\"\u003e\n \u003cp\u003eE-cigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003ePreviously smoked currently use e-cigarettes.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003eUse of both Cigarette and e-cigarette.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.970588235294118%\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.88235294117647%\"\u003e\n \u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e (L/Sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.941176470588236%\"\u003e\n \u003cp\u003e3.72\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.735294117647058%\"\u003e\n \u003cp\u003e3.25\u0026plusmn;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\"\u003e\n \u003cp\u003e3.30\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e3.38\u0026plusmn;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e2.96\u0026plusmn;0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.970588235294118%\"\u003e\n \u003cp\u003e\u0026le; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.88235294117647%\"\u003e\n \u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e (% predicted)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.941176470588236%\"\u003e\n \u003cp\u003e96.65\u0026plusmn;11.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.735294117647058%\"\u003e\n \u003cp\u003e79.40\u0026plusmn;11.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\"\u003e\n \u003cp\u003e81.45\u0026plusmn;9.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e83.08\u0026plusmn;11.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e72.6\u0026plusmn;6.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.970588235294118%\"\u003e\n \u003cp\u003e\u0026le; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.88235294117647%\"\u003e\n \u003cp\u003eFVC (L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.941176470588236%\"\u003e\n \u003cp\u003e4.23\u0026plusmn;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.735294117647058%\"\u003e\n \u003cp\u003e4.11\u0026plusmn;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\"\u003e\n \u003cp\u003e4.06\u0026plusmn;0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e4.38\u0026plusmn;0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e4.11\u0026plusmn;0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.970588235294118%\"\u003e\n \u003cp\u003e0.425\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.88235294117647%\"\u003e\n \u003cp\u003eFVC (% predicted)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.941176470588236%\"\u003e\n \u003cp\u003e92.28\u0026plusmn;18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.735294117647058%\"\u003e\n \u003cp\u003e84.2\u0026plusmn;12.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\"\u003e\n \u003cp\u003e87.91\u0026plusmn;12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e84.81\u0026plusmn;23.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e84.28\u0026plusmn;11.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.970588235294118%\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.88235294117647%\"\u003e\n \u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e/FVC (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.941176470588236%\"\u003e\n \u003cp\u003e90.39\u0026plusmn;6.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.735294117647058%\"\u003e\n \u003cp\u003e79.71\u0026plusmn;9.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\"\u003e\n \u003cp\u003e91.23\u0026plusmn;11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e80.37\u0026plusmn;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.117647058823529%\"\u003e\n \u003cp\u003e73.65\u0026plusmn;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.970588235294118%\"\u003e\n \u003cp\u003e\u0026le; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003eNote: Values are presented as Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe exploratory analysis in FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%) value showed control vs. cigarette use only 10.68 (95% CI 5.55\u0026ndash;15.8; p \u0026le; 0.001), control vs previously smoked currently use e-cigarettes 10.02 (95% CI 4.89\u0026ndash;15.15; p \u0026le; 0.001) and control vs use of both cigarette and e-cigarette 16.73(95% CI 11.61\u0026ndash;21.86; p \u0026le; 0.001) (Fig. 2A). Use of both cigarette and e-cigarette vs cigarette use only 6.05 (95% CI 0.92\u0026ndash;11.18; p = 0.001) (Fig. 2B), Use of both cigarette and e-cigarette vs e-cigarette use only 17.57 (95% CI 12.44\u0026ndash;22.7; p \u0026le; 0.001) (Fig. 2C) and Use of both cigarette and e-cigarette vs previously smoked currently use e-cigarettes 6.71 (95% CI 11.84\u0026ndash;1.58; p = 0.03) (Fig. 2D). \u0026nbsp;Also, cigarette use only vs e-cigarette use only 11.51 (95% CI 16.64\u0026ndash;6.39; p \u0026le; 0.001), e-cigarette use only vs previously smoked currently use e-cigarettes 10.86 (95% CI 5.73\u0026ndash;15.98; p \u0026le; 0.001) were significant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSix Minute walk test\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe 6MWT showed a significant difference in walking distance across the groups F (4,170) = 19.93, p \u0026le; 0.001, \u003cem\u003e\u0026eta;\u0026sup2; = 0.31.\u0026nbsp;\u003c/em\u003eThe statistical test showed a significant reduction among the control vs other groups in walked distance (Table 3). Further analysis showed a significant reduction between the control vs all groups who smoke within walking distance. Control vs cigarette use only 99.82 (95% CI 66.05\u0026ndash;133.59; p \u0026le; 0.001), control vs e-cigarette use only 76.28 (95% CI 42.51\u0026ndash;110.05; p \u0026le; 0.001), control vs previously smoked currently use e-cigarettes 100.23 (95% CI 66.46\u0026ndash;133.99; p \u0026le; 0.001) control vs use of both cigarette and e-cigarette147.55 (95% CI 113.78\u0026ndash;181.32; p \u0026le; 0.001) (Fig.3A). Similarly, significant differences were observed between the use of both cigarette and e-cigarettes and other user groups. Use of both cigarette and e-cigarette vs cigarette use only 47.72 (95% CI 81.49\u0026ndash;13.95; p = 0.001) (Fig.3B), Use of both cigarette and e-cigarette vs e-cigarette use only 71.27 (95% CI 105.03\u0026ndash;37.50; p \u0026le; 0.001) (Fig.3C), and use of both cigarette and e-cigarette vs previously smoked currently use e-cigarettes 47.32 (95% CI 81.09-13.55; p = 0.004) (Fig.3D).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"641\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003eTable 3 Six Minute walk test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.2808112324493%\"\u003e\n \u003cp\u003e6MWT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.224648985959437%\"\u003e\n \u003cp\u003eControl (n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.012480499219969%\"\u003e\n \u003cp\u003eCigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\"\u003e\n \u003cp\u003eE-cigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72854914196568%\"\u003e\n \u003cp\u003ePreviously smoked currently use e-cigarettes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.0405616224649%\"\u003e\n \u003cp\u003eUse of both cigarette and e-cigarette.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45241809672387%\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.2808112324493%\"\u003e\n \u003cp\u003eWalked Distance (m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.224648985959437%\"\u003e\n \u003cp\u003e564.42\u0026plusmn;92.95\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.012480499219969%\"\u003e\n \u003cp\u003e464.59\u0026plusmn; 59.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\"\u003e\n \u003cp\u003e488.13\u0026plusmn; 68.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72854914196568%\"\u003e\n \u003cp\u003e464.19\u0026plusmn; 76.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.0405616224649%\"\u003e\n \u003cp\u003e416.26\u0026plusmn;53.49\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45241809672387%\"\u003e\n \u003cp\u003e\u0026le; 0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.2808112324493%\"\u003e\n \u003cp\u003ePost 6MWT Dyspnea Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.224648985959437%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.012480499219969%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72854914196568%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.0405616224649%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45241809672387%\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.2808112324493%\"\u003e\n \u003cp\u003ePost 6MWT SPO2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.224648985959437%\"\u003e\n \u003cp\u003e99.28\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.012480499219969%\"\u003e\n \u003cp\u003e99.2\u0026plusmn;1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\"\u003e\n \u003cp\u003e99.11\u0026plusmn;1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72854914196568%\"\u003e\n \u003cp\u003e99.37\u0026plusmn;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.0405616224649%\"\u003e\n \u003cp\u003e99.2\u0026plusmn;0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45241809672387%\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003eNote: Values are presented as Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHealth-related quality of life (HRQoL)\u003cstrong\u003e\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SF-36 questionnaire indicated a significant reduction in three domains physical function H= (4) 20.55, p \u0026le; 0.001, emotional well-being H (4)= 19.21, p =0.001 and social function H (4) \u0026nbsp;= 29.63, p \u0026le; 0.001. Further exploratory analysis in the physical function domain showed a significant difference between control vs cigarette use only (p=0.03), control vs e-cigarette use only (p=0.04) and control vs use of both cigarette and e-cigarette (p \u0026le; 0.001). In the emotional well-being domain control vs cigarette use only (p=0.04), control vs previously smoked currently use e-cigarettes (p=0.004) and control vs use of both cigarette and e-cigarette (p = 0.003) were significantly different. In the social function domain use of both cigarette and e-cigarette vs control (p\u0026le; 0.001), use of both cigarette and e-cigarette vs cigarette use only (p=0.01), use of both cigarette and e-cigarette vs e-cigarette use only (p=0.003) and use of both cigarette and e-cigarettevs previously smoked currently use e-cigarettes (p=0.004) were significant. \u0026nbsp;(Table 4) represents the comparison of HRQoL between the groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"669\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003eTable 4 Health Related Quality of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eSF-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003eControl (n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003eCigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003eE-cigarette use only\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003ePreviously smoked currently use e-cigarettes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003eUse of both cigarette and e-cigarette.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003ePhysical functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e100(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e85(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e90(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e90(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e90(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e\u0026le; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eRole limitations due to physical health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e100(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e100(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e95(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e100(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e90(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eRole limitation due to emotional problem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e90(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e100(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e95(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e90(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e80(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eEnergy fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e80(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e80(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e80(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e75(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e80(13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eEmotional well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e90(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e80(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e80(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e80(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e76(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eSocial function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e90(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e87.5 (31.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e80(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e87.5(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e75(17.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e\u0026le; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e90(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e90(22.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e100(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e87.5(22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e80.5(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eGeneral Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e85(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e80(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e80(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e80(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e80(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.318385650224215%\"\u003e\n \u003cp\u003eHealth change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.659192825112108%\"\u003e\n \u003cp\u003e80(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.452914798206278%\"\u003e\n \u003cp\u003e75(35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.762331838565023%\"\u003e\n \u003cp\u003e80(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.246636771300448%\"\u003e\n \u003cp\u003e75(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.143497757847534%\"\u003e\n \u003cp\u003e75(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.417040358744394%\"\u003e\n \u003cp\u003e0.300\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003eNote: Values are presented as Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study shows a decline in lung function parameters, exercise capacity, and quality of life in individuals who use cigarettes and e-cigarettes for the long term compared to individuals who never smoked or vaped. Furthermore, worse lung function status, exercise capacity, and quality of life were observed among those who used both cigarettes and e-cigarettes. The reduction in lung function associated with both short and long-term use of cigarette smoking is well established\u0026nbsp;(22). However, evidence regarding the health outcomes of vaping and dual use is still emerging and its long-term cardiopulmonary effects are largely unknown\u0026nbsp;(23).\u003c/p\u003e\n\u003cp\u003eThe lung function studies reported in vaping are primarily of short-term usage, while the current study reports the characteristics of long-term users (3.5 years or more). A reduction in lung function parameters\u0026nbsp;such as in FEV\u003csub\u003e1\u003c/sub\u003e, mid-expiratory flow rates FEV1/FVC ratio\u0026nbsp;and DLCO were reported by Meo \u003cem\u003eet al\u0026nbsp;\u003c/em\u003eand Antoneiwich \u003cem\u003eet al\u0026nbsp;\u003c/em\u003e(24, 25). Whereas other similar studies reported no\u0026nbsp;changes in the FEV\u003csub\u003e1\u0026nbsp;\u003c/sub\u003eor FEV\u003csub\u003e1\u003c/sub\u003e/FVC ratio in those who used e-cigarettes for short-term (26, 27). \u0026nbsp;The present study observed a significant reduction in\u0026nbsp;FEV1 and walked distance among those who only used e-cigarettes compared to those who never smoked or vaped.\u0026nbsp;Contrary to our findings, Polosa \u003cem\u003eet al\u003c/em\u003e long-term follow-up study of individuals who use e-cigarettes reported no significant difference in lung function, respiratory symptoms and lung imaging compared to never users (28). The variations in the study characteristics, such as the duration of vape (median\u0026nbsp;(IQR) 5 (1) years and median (range) 8 (3.5 -15) months in their study) and sample size (135 vs 21) are the possible rationale for the differences in the outcomes.\u0026nbsp;Interestingly, no previous studies reported long-term changes in lung function among individuals who use both cigarettes and e-cigarettes, while current study findings point out a significant decline in lung function such as FEV\u003csub\u003e1\u0026nbsp;\u003c/sub\u003e(L/sec) and FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%)\u0026nbsp;among those who used both cigarette and e-cigarettes.\u003c/p\u003e\n\u003cp\u003eThe inhalation of nicotine and other chemicals in both cigarettes and e-cigarettes impairs the oxygen uptake and its utilization by the body leading to a decline in exercise capacity (29-32). In the current study, compared to those who never smoked or vaped all the user groups had a significant reduction in walked distance with individuals who use both cigarettes and e-cigarettes being affected the most. Similarly,\u0026nbsp;Dinkelo \u003cem\u003eet al\u003c/em\u003e reported the physical training and fitness among people who smoke cigarettes and e-cigarettes. In their study, overall physical training was highest among never users, followed by individuals who vaped, smoked, and those who used both (33). The reduction in lung function, exercise capacity, and respiratory symptoms among people who use cigarettes and e-cigarettes impede the ability to participate in daily activities and ultimately impact overall well-being and quality of life (34, 35). In our study, there was a significant reduction in the physical function domain which includes limitations in performing moderate to vigorous daily activities was observed among participants who use cigarettes and e-cigarettes. Furthermore, a significant decline in emotional well-being and social function domains was also observed in the smoking groups which is consistent with the existing evidence linking mental health comorbidities with smoking and vaping (36, 37). Interestingly, the use of both cigarettes and e-cigarettes reported worse scores in emotional well-being and social function compared to other types of users.\u0026nbsp;Similar to our study findings, the use of both cigarettes and e-cigarettes was previously reported to have a worse SF-12 general health score and breathing difficulty score compared to people who smoke cigarettes only\u0026nbsp;(16).\u003c/p\u003e\n\u003cp\u003ePeople who use both cigarette and e-cigarettes reportedly initiate e-cigarettes as a safer alternative for nicotine delivery and to quit smoking (38). However, people who use e-cigarettes end up using both possibly due to either higher nicotine dependence or dissatisfaction with lower levels of nicotine in the vape (39-41). In our study lung function parameters, such as FEV\u003csub\u003e1\u003c/sub\u003e (L/sec) among those who used both cigarettes and e-cigarettes showed a difference of 20.43% compared to control, 8.92% compared to those who used cigarettes only, 10.30% compared to those who used e-cigarettes only and 12.42% compared to those who previously smoked currently use e-cigarettes. Similarly, FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%) showed a difference of 18.51% compared to control, 7.60% compared to those who used cigarettes only, 19.3% compared to those who use e-cigarettes only and 8.4% compared to individuals who previously smoked and currently use e-cigarettes compared to those who use both cigarette and e-cigarettes respectively. Also, no previous studies reported long-term changes in lung function among individuals who use both cigarettes and e-cigarettes, making this study one of its kind. However, the decline in cardiopulmonary fitness and quality of life among those who use both cigarettes and e-cigarettes aligned with previous study findings (16, 33).\u003c/p\u003e\n\u003cp\u003eOur study limitations include a low number of female participants, and not measuring the inflammatory biomarkers and oxidative stress markers which would have provided further information on systemic effects of cigarettes and e-cigarettes. Also, in the Middle East hookah (waterpipe) smoking is a common practice and we have not included them in the study. Future research focusing on the biomarkers of e-cigarette-related inflammatory and oxidative stress outcomes may yield more insightful findings for evaluating the long-term health implications of vape and dual usage.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study demonstrate a significant long-term impairment in lung function, cardiopulmonary capacity, and quality of life among people who smoke cigarettes and e-cigarettes compared to those who never smoked or vaped. Also, individuals who use both cigarettes and e-cigarettes showed worse health outcomes compared to those who never smoked or only used either cigarettes or e-cigarettes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eInstitutional Ethical approval was obtained, and consent form was obtained from every participant. The links to access the ethical approval and format of the participant consent form used are shared below.\u003c/p\u003e\n\u003cp\u003eAppendix 1 Ethical approval - Long-Term Cardiopulmonary Outcomes and Quality of Life A Comparative Study Among Cigarette, Electronic Cigarette and dual use.PDF\u003c/p\u003e\n\u003cp\u003eAppendix 2 Consumer consent to participate - Long-Term Cardiopulmonary Outcomes and Quality of Life A Comparative Study Among Cigarette, Electronic Cigarette and dual use.pdf\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe had adhered to relevant data protection laws and regulations to safeguard the privacy of research participants by adapting anonymization by removing any identifying information / media from the published data or results to prevent individuals from being identifiable and using pseudonyms or codes instead of using their real names to protect their identities or any other details. Participants are also explained about the presenting/publishing the scientific details of the study upon completion of the research.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe data set for this research can be assessed through he below link:\u003c/p\u003e\n\u003cp\u003eAppendix 3 Data and Materials - Long-Term Cardiopulmonary Outcomes and Quality of Life A Comparative Study Among Cigarette, Electronic Cigarette and dual use.xlsx\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests:\u003c/u\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e: The authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026apos; contributions:\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor name\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eContribution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eGokul G. Krishna\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eConception, Design of work, Draft the work\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eAnn Mary Jose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eDesign of work, Draft the work\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eWeaam A. Rahali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eDesign of work, Draft the work\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eWejdan W. Alyamani\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eThe acquisition, analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eManahel A Mohammed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eThe acquisition, analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eBasmah S. Alghamdi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eThe acquisition, analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eMazen M. Homoud\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eSubstantively revised it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eMohammed D. Al-Ahmari\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eSubstantively revised it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eSaleh R. Alkhathami\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eSubstantively revised it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eJithin K. Sreedharan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eSubstantively revised it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eKhalid S. Alwadeai\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eSubstantively revised it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eAyedh D. Al-Ahmari\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003eDraft the work, substantively revised it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e: No acknowledgments.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRostron B. Brief report: smoking-attributable mortality in the United States. Epidemiology. 2011:350-5.\u003c/li\u003e\n\u003cli\u003eOrganization WH. WHO report on the global tobacco epidemic 2015: raising taxes on tobacco: World Health Organization; 2015.\u003c/li\u003e\n\u003cli\u003eHenningfield JE, Zaatari G. Electronic nicotine delivery systems: emerging science foundation for policy. Tobacco Control. 2010;19(2):89-90.\u003c/li\u003e\n\u003cli\u003eLim H-H, Shin H-S. Measurement of aldehydes in replacement liquids of electronic cigarettes by headspace gas chromatography-mass spectrometry. 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Effects of e‐cigarettes and vaping devices on cardiac and pulmonary physiology. The Journal of physiology. 2020;598(22):5039-62.\u003c/li\u003e\n\u003cli\u003eAntoniewicz L, Brynedal A, Hedman L, Lundb\u0026auml;ck M, Bosson JA. Acute effects of electronic cigarette inhalation on the vasculature and the conducting airways. Cardiovascular toxicology. 2019;19:441-50.\u003c/li\u003e\n\u003cli\u003eMeo SA, Ansary MA, Barayan FR, Almusallam AS, Almehaid AM, Alarifi NS, et al. Electronic cigarettes: impact on lung function and fractional exhaled nitric oxide among healthy adults. American Journal of Men\u0026apos;s health. 2019;13(1):1557988318806073.\u003c/li\u003e\n\u003cli\u003eVardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest. 2012;141(6):1400-6.\u003c/li\u003e\n\u003cli\u003eFerrari M, Zanasi A, Nardi E, Morselli Labate AM, Ceriana P, Balestrino A, et al. Short-term effects of a nicotine-free e-cigarette compared to a traditional cigarette in smokers and non-smokers. BMC pulmonary medicine. 2015;15(1):1-9.\u003c/li\u003e\n\u003cli\u003ePolosa R, Cibella F, Caponnetto P, Maglia M, Prosperini U, Russo C, et al. Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked. Scientific reports. 2017;7(1):13825.\u003c/li\u003e\n\u003cli\u003eMacera CA, Aralis HJ, MacGregor AJ, Rauh MJ, Han PP, Galarneau MR. Cigarette smoking, body mass index, and physical fitness changes among male navy personnel. Nicotine \u0026amp; Tobacco Research. 2011;13(10):965-71.\u003c/li\u003e\n\u003cli\u003ePintican D, Mihu D. Influence of smoking on exercise capacity. Palestrica of the Third Millennium Civilization \u0026amp; Sport. 2015;16(2).\u003c/li\u003e\n\u003cli\u003eRidner SL, Keith RJ, Walker KL, Hart JL, Newton KS, Crawford TN. Differences in quality of life among college student electronic cigarette users. AIMS Public Health. 2018;5(4):454.\u003c/li\u003e\n\u003cli\u003eKerr DM, Brooksbank KJ, Taylor RG, Pinel K, Rios FJ, Touyz RM, et al. Acute effects of electronic and tobacco cigarettes on vascular and respiratory function in healthy volunteers: a cross-over study. Journal of hypertension. 2019;37(1):154-66.\u003c/li\u003e\n\u003cli\u003eDinkeloo E, Grier TL, Brooks RD, Jones BH. Vaping, smoking, and the physical fitness of active young men. American Journal of Preventive Medicine. 2020;58(1):e31-e7.\u003c/li\u003e\n\u003cli\u003eGeneral USPHSOotS. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General: US Department of Health and Human Services, Public Health Service, Office of \u0026hellip;; 2010.\u003c/li\u003e\n\u003cli\u003eWang MP, Ho SY, Leung LT, Lam TH. Electronic cigarette use and respiratory symptoms in Chinese adolescents in Hong Kong. JAMA pediatrics. 2016;170(1):89-91.\u003c/li\u003e\n\u003cli\u003eHeiligenstein E, Smith SS. Smoking and Mental Health Problems in Treatment-Seeking University Students. Nicotine \u0026amp; Tobacco Research. 2006;8(4):519-23.\u003c/li\u003e\n\u003cli\u003eBecker TD, Arnold MK, Ro V, Martin L, Rice TR. Systematic review of electronic cigarette use (vaping) and mental health comorbidity among adolescents and young adults. Nicotine and Tobacco Research. 2021;23(3):415-25.\u003c/li\u003e\n\u003cli\u003ePokhrel P, Herzog TA, Muranaka N, Regmi S, Fagan P. Contexts of cigarette and e-cigarette use among dual users: a qualitative study. BMC public health. 2015;15:1-9.\u003c/li\u003e\n\u003cli\u003eBullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tobacco control. 2010;19(2):98-103.\u003c/li\u003e\n\u003cli\u003eVansickel AR, Cobb CO, Weaver MF, Eissenberg TE. A clinical laboratory model for evaluating the acute effects of electronic \u0026ldquo;cigarettes\u0026rdquo;: nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiology, Biomarkers \u0026amp; Prevention. 2010;19(8):1945-53.\u003c/li\u003e\n\u003cli\u003eBenowitz NL, Donny EC, Hatsukami DK. Reduced nicotine content cigarettes, e-cigarettes and the cigarette end game. Addiction (Abingdon, England). 2017;112(1):6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"electronic cigarettes, cigarette smoking, e-cigarettes, smoking, tobacco, respiratory, dual use ","lastPublishedDoi":"10.21203/rs.3.rs-4200243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4200243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Smoking is a leading cause of heart and lung diseases worldwide. Though there is a decline in tobacco smoking the use of e-cigarettes is growing in popularity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To assess the long-term effects of smoking, vaping, and dual use on cardiopulmonary function capacity and quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study participants were classified into five groups: Control, Individuals who use cigarettes only, Individuals who only use e-cigarettes, Individuals who previously smoked and currently use only e-cigarettes and Individuals who use both cigarettes and e-cigarettes. Participants performed PFT, 6MWT and completed HRQoL questionnaire.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eResults:\u003c/strong\u003e A total of 175(85.7% male) participants with an average age of mean(±SD)27.38(±5.75) enrolled in the study. PFT results showed significant difference in FEV\u003csub\u003e1\u003c/sub\u003e(L/Sec) [F (4,170) = 7.73, p≤ 0.001] η²=0.15; FEV\u003csub\u003e1\u003c/sub\u003e(%predicted) [F (4,170) =24.63, p≤0.001] η²=0.36; and FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%) [F (4,170) =16.85, p≤0.001] η² = 0.28 values across the five groups. On further analysis, FEV\u003csub\u003e1\u003c/sub\u003e and FEV\u003csub\u003e1 \u003c/sub\u003e(%predicted) significantly decreased in all user groups. Similarly, in FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%) significant difference was observed with user groups except those who only use e-cigarettes. 6MWT showed a significant difference in walking distance [F (4,170) = 19.93, p≤0.001] η² =0.31. HRQoL reported a significant difference in physical function [H (4) =20.55, p≤0.001], emotional well-being [H (4) =19.21, p=0.001], and social function [H (4) =29.63, p≤0.001] domains. Individuals who use both cigarettes and e-cigarettes reported a significant decline in lung function [(FEV\u003csub\u003e1\u003c/sub\u003e 2.96±0.41, FEV\u003csub\u003e1 \u003c/sub\u003e(% predicted) 72.6±6.07 and FEV\u003csub\u003e1\u003c/sub\u003e/FVC (%) 73.65±11], 6MWT walking distance(m) (mean ±SD) 416.26±53.49.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: We\u003c/strong\u003e observed a significant long-term impairment in lung function, cardiopulmonary capacity, and quality of life among individuals who use cigarettes and e-cigarettes compared to those who never smoked or vaped. Also, individuals who use both cigarettes and e-cigarettes showed the worst health outcomes.\u003c/p\u003e","manuscriptTitle":"Long-Term Cardiopulmonary Outcomes and Quality of Life: A Comparative Study Among Cigarette, Electronic Cigarette and Dual use Consumers.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-09 21:12:54","doi":"10.21203/rs.3.rs-4200243/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7ea4bdb-8596-42c3-a346-0117c9419ae5","owner":[],"postedDate":"April 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T17:46:18+00:00","versionOfRecord":{"articleIdentity":"rs-4200243","link":"https://doi.org/10.3389/fpubh.2025.1707230","journal":{"identity":"frontiers-in-public-health","isVorOnly":true,"title":"Frontiers in Public Health"},"publishedOn":"2026-01-13 00:00:00","publishedOnDateReadable":"January 13th, 2026"},"versionCreatedAt":"2024-04-09 21:12:54","video":"","vorDoi":"10.3389/fpubh.2025.1707230","vorDoiUrl":"https://doi.org/10.3389/fpubh.2025.1707230","workflowStages":[]},"version":"v1","identity":"rs-4200243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4200243","identity":"rs-4200243","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}