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We systematically reviewed the human biomonitoring evidence and quantified changes in biomarkers of exposure after complete switching from cigarettes to e-cigarettes or exclusive e-cigarette use after cigarette smoking.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>PubMed, Scopus and Web of Science Core Collection were searched from inception to 28 May 2026 for human studies reporting biomarkers of exposure or potential harm in relation to e-cigarette use, dual use or switching. Study characteristics, biomarker data and a pragmatic risk-of-bias and funding assessment were extracted in duplicate. Meta-analysis was restricted to biomarkers of exposure with at least two compatible estimates for complete switching or exclusive e-cigarette use after cigarette smoking; dual-use evidence was synthesised narratively. Effects were expressed as ratios of means comparing post-switch with baseline or reference cigarette-smoking levels and pooled using random-effects models with restricted maximum likelihood estimation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Sixty studies were included. Six publications, representing seven study-level sources, contributed 47 biomarker-specific effects across ten biomarkers. Complete switching or exclusive e-cigarette use after cigarette smoking was associated with lower levels of every pooled biomarker. Approximate reductions were 61% for NNAL, 92% for NNN, 72% for 3-HPMA, 84% for the acrylonitrile metabolite CEMA, 77% for HMPMA, 82% for MHBMA, 90% for S-PMA, 79% for exhaled carbon monoxide, 77% for carboxyhaemoglobin and 76% for 1-OHP. Between-study heterogeneity was substantial for most biomarkers (I\u00b2 57\u201399%), and 95% prediction intervals lay entirely below 1.0 only for NNN, CEMA and carboxyhaemoglobin; the pooled values are therefore central estimates rather than precise expectations for any individual future study. Narrative evidence was broadly consistent: exclusive e-cigarette use was generally associated with lower exposure than cigarette smoking, whereas reductions among dual users were smaller and depended on cigarette displacement. Biomarkers of potential harm were more heterogeneous and were not pooled. Many switching studies were short-term, product-specific and industry-funded.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Complete switching from cigarettes to e-cigarettes or exclusive e-cigarette use after cigarette smoking is associated with substantially lower biomarkers of exposure to tobacco- and combustion-related toxicants. Exposure reductions appear greatest when cigarette smoking is fully displaced. These findings describe reduced exposure to measured toxicants; they do not, by themselves, establish reduced disease risk or long-term safety.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00204-026-04583-w","type":"journal-article","created":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T19:47:22Z","timestamp":1792784842000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Changes in human biomarkers of exposure after complete switching from cigarettes to e-cigarettes or exclusive e-cigarette use: a systematic review and biomarker-specific meta-analysis"],"prefix":"10.1007","author":[{"given":"Yusuff Adebayo","family":"Adebisi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Max","family":"Scherer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikola","family":"Pluym","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anas Ali","family":"Alhur","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Venera","family":"Tomaselli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Riccardo","family":"Polosa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,23]]},"reference":[{"issue":"9","key":"4583_CR1","doi-asserted-by":"publisher","first-page":"1277","DOI":"10.1002\/mnfr.201100481","volume":"55","author":"K Abraham","year":"2011","unstructured":"Abraham K, Andres S, Palavinskas R, Berg K, Appel KE, Lampen A (2011) Toxicology and risk assessment of acrolein in food. 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Institutional research ethics approval was therefore not required.Not applicable. This study did not recruit human participants and used aggregate data from previously published research.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable. The manuscript contains no identifiable information relating to individual participants.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Yusuff Adebayo Adebisi previously received funding through the Tobacco Harm Reduction Scholarship and the Kevin Molloy Fellowship, both awarded by Knowledge Action Change, United Kingdom, an independent public health organisation. Knowledge Action Change receives funding from Global Action to End Smoking, an independent United States 501(c)(3) nonprofit grantmaking organisation that supports health and science research, cessation education and agricultural transformation initiatives. Neither award provided funding for the present study. Max Scherer and Nikola Pluym are employees of ABF Analytisch-Biologisches Forschungslabor GmbH, an independent contract research laboratory. ABF has previously received funding for tobacco- and nicotine-related biomarker research from the Foundation for a Smoke-Free World, now Global Action to End Smoking. Max Scherer and Nikola Pluym declare no other relevant financial or non-financial interests. Riccardo Polosa is a Full Professor of Internal Medicine and Medical Director of the Institute for Internal Medicine at the University of Catania, Italy. He has received competitive grants from the European Union and governmental sources, including U-BIOPRED, AIR-PROM, the Integral Rheumatology and Immunology Specialists Network, and grants funded by the European Commission through NextGenerationEU under PNRR 3277\/2021, PNRR 341\/2022 and PNRR 411\/2021. He has also received investigator-initiated research funding from Global Action to End Smoking, Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A\/S, Sandoz, Merck Sharp & Dohme, Boehringer Ingelheim, Novartis, Arbi Group Srl, Duska Therapeutics and Forest Laboratories. He has received consultancy fees from Pfizer, Boehringer Ingelheim, Duska Therapeutics, Forest Laboratories, CV Therapeutics, Sermo Inc., GRG Health, Clarivate Analytics, Guidepoint Expert Network and GLG Group, and receives textbook royalties from Elsevier and EDRA. He is the founder of the Center for Tobacco Prevention and Treatment and the Center of Excellence for the Acceleration of Harm Reduction at the University of Catania. He serves as Chair of the European Committee for Standardization Technical Committee on requirements and test methods for emissions of electronic cigarettes (CEN\/TC 437, Working Group 4) and as a scientific advisor to the nonprofit Foundation RIDE2Med.Anas Ali Alhur and Venera Tomaselli declare that they have no relevant financial or non-financial interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}]}}