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Exposure to Tobacco Specific Nitrosamines among people who vape, 

smoke or do neither. A Systematic Review and Meta Analysis Abstract
Background: Smoking exposes people to high levels of 

Tobacco-Specific Nitrosamines (TSNAs), which include potent 

carcinogens. We systematically reviewed TSNA exposure 

between people smoking, vaping and doing neither.

Methods: Databases were searched between August 

2017-March 2022, using vaping related terms. Peer-reviewed 

articles reporting TSNA metabolites (NNAL,NNN,NAB,NAT)

 levels in bio-samples among adults exclusively vaping, exclusively 

smoking, or doing neither were included. Where possible, 

meta-analyses were conducted.

Results: Of 12,781 identified studies, 22 were included. TSNA levels

 fell substantially when people who smoke switched to vaping in 

longitudinal studies and were lower among people who vaped 

compared to smoked in cross-sectional studies. Levels of TSNAs were

 similar when comparing 

people who switched from smoking to vaping, to those who 

switched to no use of nicotine products, in longitudinal studies.

 Levels were higher among people who vaped compared to people

 who neither vaped nor smoked in cross-sectional studies.When 

comparing people who vaped to smoked: pooled urinary NNAL 

was 79% lower across three randomised controlled trials and 96% 

lower across three cross-sectional studies; pooled NAB was 87% lower 

and NAT 94% lower in two cross-sectional studies. When comparing 

people who neither vaped nor smoked to people who vaped, pooled 

urinary NNAL was 80%, NAB 26%, and NAT 27% lower in two 

cross-sectional studies. Other longitudinal data, and NNN levels 

could not be pooled.

Conclusions: Exposure to all TSNAs was lower among people who vaped 

compared to people who smoked. Levels were higher among people who 

vaped compared to people who neither vaped nor smoked.

Time:2023 Nov 11