{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T07:13:28Z","timestamp":1792826008733,"version":"4.5.0"},"reference-count":43,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2025,4,15]],"date-time":"2025-04-15T00:00:00Z","timestamp":1744675200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"funder":[{"name":"Intramural Research Department"},{"DOI":"10.13039\/100000048","name":"American Cancer Society","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000048","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,8,22]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Dual use of combustible cigarettes and e-cigarettes is the most common multiple tobacco-use behavior in the United States, but its long-term health impact remains unclear. Biomarkers of exposure (BOE) can help identify potential health risks of dual use.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We analyzed data from 2,679 adult participants from Wave 5 of the Population Assessment on Tobacco and Health Study, a U.S. nationally representative study, including individuals reporting current exclusive cigarette use (n\u2005=\u20051,913), exclusive e-cigarette use (n\u2005=\u2005316), and dual use (n\u2005=\u2005450). Eight subgroups were created based on self-reported high\/low (above\/below mean) cigarettes per day (CPD) and days of e-cigarette use in past the 30 days (ECIG). Adjusted geometric mean concentrations were compared for total nicotine equivalents, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), three volatile organic compounds (VOCs), and heavy metals (lead and cadmium).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Individuals reporting dual use did not differ from those reporting exclusive cigarette use on CPD (13.1 vs. 11.8, respectively). Dual-use groups with high CPD had higher levels of NNAL and VOCs compared to those with low CPD (eg, NNAL for high CPD\/high ECIG: 257.07\u00a0ng\/mg creatinine vs. low CPD\/high ECIG: 64.57\u00a0ng\/mg creatinine, p\u2005&amp;lt;\u2005.001; high CPD\/low ECIG: 312.02\u00a0ng\/mg creatinine vs. low CPD\/low ECIG: 144.11\u00a0ng\/mg creatinine, p\u2005&amp;lt;\u2005.001). Cigarette use (dual or exclusive use) was generally associated with higher BOE than exclusive e-cigarette use, though metal exposure did not differ between groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Dual use and exclusive cigarette use are associated with higher toxicant exposure compared to exclusive e-cigarette use.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Implications<\/jats:title>\n                    <jats:p>In this population-based cross-sectional study, individuals reporting dual use appear to have nicotine and toxicant exposure at least at the same level as those using cigarettes alone and higher than exclusive e-cigarette use (except for metals). Given the adverse health consequences of dual use, including potential cancer risk, our findings highlight the need for clinicians and public health practitioners to increase awareness of the potential risks associated with dual use.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ntr\/ntaf053","type":"journal-article","created":{"date-parts":[[2025,2,28]],"date-time":"2025-02-28T15:36:05Z","timestamp":1740756965000},"page":"1591-1599","source":"Crossref","is-referenced-by-count":19,"title":["Nicotine and Toxicant Exposure among Individuals using both Combustible Cigarettes and E-cigarettes Based on Level of Product Use"],"prefix":"10.1093","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1237-9356","authenticated-orcid":false,"given":"Zheng","family":"Xue","sequence":"first","affiliation":[{"name":"Tobacco Control Research Group, Surveillance & Health Equity Science, American Cancer Society , Atlanta, GA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eva","family":"Orr-Souza","sequence":"additional","affiliation":[{"name":"Tobacco Control Research Group, Surveillance & Health Equity Science, American Cancer Society , Atlanta, GA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4501-1398","authenticated-orcid":false,"given":"Nigar","family":"Nargis","sequence":"additional","affiliation":[{"name":"Tobacco Control Research Group, Surveillance & Health Equity Science, American Cancer Society , Atlanta, GA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Minal","family":"Patel","sequence":"additional","affiliation":[{"name":"Tobacco Control Research Group, Surveillance & Health Equity Science, American Cancer Society , Atlanta, GA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8954-8763","authenticated-orcid":false,"given":"Tyler","family":"Nighbor","sequence":"additional","affiliation":[{"name":"Tobacco Control Research Group, Surveillance & Health Equity Science, American Cancer Society , Atlanta, GA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,4,15]]},"reference":[{"issue":"2","key":"2025102400413819000_CIT0001","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1136\/tobaccocontrol-2021-056544","article-title":"Evolution of tobacco products: recent history and future directions","volume":"31","author":"O\u2019Connor","year":"2022","journal-title":"Tob Control."},{"issue":"3","key":"2025102400413819000_CIT0002","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1136\/tc-2022-057495","article-title":"Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies","volume":"33","author":"Asfar","year":"2024","journal-title":"Tob Control."},{"issue":"1","key":"2025102400413819000_CIT0003","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1007\/s11739-021-02835-4","article-title":"A scoping review of studies on the health impact of electronic nicotine delivery systems","volume":"17","author":"Hajat","year":"2022","journal-title":"Intern Emerg Med."},{"key":"2025102400413819000_CIT0004","doi-asserted-by":"publisher","first-page":"105770","DOI":"10.1016\/j.ypmed.2019.105770","article-title":"The cardiovascular effects of electronic cigarettes: a systematic review of experimental studies","volume":"127","author":"Kennedy","year":"2019","journal-title":"Prev Med."},{"issue":"9","key":"2025102400413819000_CIT0005","doi-asserted-by":"publisher","first-page":"1722","DOI":"10.1080\/02770903.2021.1971703","article-title":"Association between e-cigarette use and asthma: a systematic review and meta-analysis","volume":"59","author":"Chand","year":"2022","journal-title":"J Asthma."},{"issue":"6","key":"2025102400413819000_CIT0006","doi-asserted-by":"publisher","first-page":"953","DOI":"10.1016\/j.amepre.2022.01.015","article-title":"Association between E-cigarettes and asthma in adolescents: a systematic review and meta-analysis","volume":"62","author":"Li","year":"2022","journal-title":"Am J Prev Med."},{"issue":"June","key":"2025102400413819000_CIT0007","doi-asserted-by":"publisher","first-page":"100077","DOI":"10.1016\/j.addicn.2023.100077","article-title":"Biomarkers of Electronic Nicotine Delivery Systems (ENDS) use","volume":"6","author":"Goniewicz","year":"2023","journal-title":"Addict Neurosci"},{"key":"2025102400413819000_CIT0008","volume-title":"Harmful and Potentially Harmful Constituents in Tobacco Products and Tobacco Smoke: Established List","author":"U.S. Food & Drug Adminstration","year":"2012"},{"issue":"8","key":"2025102400413819000_CIT0009","doi-asserted-by":"publisher","first-page":"e185937","DOI":"10.1001\/jamanetworkopen.2018.5937","article-title":"Comparison of nicotine and toxicant exposure in users of electronic cigarettes and combustible cigarettes","volume":"1","author":"Goniewicz","year":"2018","journal-title":"JAMA Netw Open"},{"issue":"1","key":"2025102400413819000_CIT0010","doi-asserted-by":"publisher","first-page":"16103","DOI":"10.20452\/pamw.16103","article-title":"Health risks of dual use of electronic and combustible cigarettes: exposure to acrylamide and glycidamide","volume":"132","author":"Cheng","year":"2022","journal-title":"Pol Arch Intern Med"},{"issue":"2","key":"2025102400413819000_CIT0011","doi-asserted-by":"publisher","first-page":"e2147891","DOI":"10.1001\/jamanetworkopen.2021.47891","article-title":"Exposure to toxicants associated with use and transitions between cigarettes, E-cigarettes, and no tobacco","volume":"5","author":"Dai","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"1","key":"2025102400413819000_CIT0012","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1186\/s13690-023-01070-x","article-title":"Smoking is associated with elevated blood level of volatile organic compounds: a population-based analysis of NHANES 2017-2018","volume":"81","author":"Wu","year":"2023","journal-title":"Archives of Public Health = Archives belges de sante publique"},{"issue":"3","key":"2025102400413819000_CIT0013","doi-asserted-by":"publisher","first-page":"424","DOI":"10.1136\/tobaccocontrol-2020-055967","article-title":"Transitions between cigarette, ENDS and dual use in adults in the PATH study (waves 1\u20134): multistate transition modelling accounting for complex survey design","volume":"31","author":"Brouwer","year":"2022","journal-title":"Tob Control."},{"issue":"8","key":"2025102400413819000_CIT0014","doi-asserted-by":"publisher","first-page":"4373","DOI":"10.3390\/ijerph18084373","article-title":"E-cigarette flavors and frequency of e-cigarette use among adult dual users who attempt to quit cigarette smoking in the united states: longitudinal findings from the PATH study 2015\/16-2016\/17","volume":"18","author":"Kasza","year":"2021","journal-title":"Int J Environ Res Public Health."},{"issue":"5","key":"2025102400413819000_CIT0015","doi-asserted-by":"publisher","first-page":"790","DOI":"10.1093\/ntr\/ntaa252","article-title":"Exposure to nicotine and toxicants among dual users of tobacco cigarettes and e-cigarettes: population assessment of tobacco and health (PATH) study, 2013-2014","volume":"23","author":"Smith","year":"2021","journal-title":"Nicotine & Tobacco Research"},{"issue":"November","key":"2025102400413819000_CIT0016","doi-asserted-by":"publisher","first-page":"106218","DOI":"10.1016\/j.ypmed.2020.106218","article-title":"Cluster analysis of urinary tobacco biomarkers among U.S. adults: Population Assessment of Tobacco and Health (PATH) biomarker study (2013-2014)","volume":"140","author":"Majeed","year":"2020","journal-title":"Prev Med."},{"issue":"18","key":"2025102400413819000_CIT0017","doi-asserted-by":"publisher","first-page":"475","DOI":"10.15585\/mmwr.mm7218a1","article-title":"Tobacco product use among adults \u2013 United States, 2021","volume":"72","author":"Cornelius","year":"2023","journal-title":"MMWR Morb Mortal Wkly Rep."},{"key":"2025102400413819000_CIT0018","article-title":"E-Cigarette Devices","volume-title":"Public Health Consequences of E-Cigarettes","author":"National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice","year":"2018"},{"issue":"1","key":"2025102400413819000_CIT0019","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1136\/tobaccocontrol-2017-054174","article-title":"Transitions in electronic cigarette use among adults in the population assessment of tobacco and health (PATH) study, waves 1 and 2 (2013\u20132015)","volume":"28","author":"Coleman","year":"2019","journal-title":"Tob Control."},{"issue":"October","key":"2025102400413819000_CIT0020","doi-asserted-by":"publisher","first-page":"101009","DOI":"10.1016\/j.pmedr.2019.101009","article-title":"Patterns and trends of dual use of e-cigarettes and cigarettes among U.S. adults, 2015\u20132018","volume":"16","author":"Owusu","year":"2019","journal-title":"Prev Med Rep"},{"issue":"S1","key":"2025102400413819000_CIT0021","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1111\/add.14570","article-title":"A new classification system for describing concurrent use of nicotine vaping products alongside cigarettes (so-called \u2018dual use\u2019): findings from the ITC-4 Country Smoking and Vaping wave 1 Survey","volume":"114","author":"Borland","year":"2019","journal-title":"Addiction."},{"issue":"September","key":"2025102400413819000_CIT0022","doi-asserted-by":"publisher","first-page":"100103","DOI":"10.1016\/j.heha.2024.100103","article-title":"Association between prolonged dual use of cigarettes and E-cigarettes and psychosocial factors among U.SSmokers: Secondary data analysis from the 2013 to 2019 PATH study","volume":"11","author":"Chen","year":"2024","journal-title":"Hyg Environ Health Adv"},{"issue":"1","key":"2025102400413819000_CIT0023","doi-asserted-by":"publisher","first-page":"124","DOI":"10.1136\/tobaccocontrol-2021-056483","article-title":"Electronic cigarette use intensity measurement challenges and regulatory implications","volume":"32","author":"Soule","year":"2023","journal-title":"Tob Control."},{"key":"2025102400413819000_CIT0024","doi-asserted-by":"publisher","DOI":"10.3886\/ICPSR36231.v40","author":"United States Department of Health and Human Services. National Institutes of Health. National Institute on Drug Abuse, United States Department of Health and Human Services","year":"2024","journal-title":"Food and Drug Administration. Center for Tobacco Products. Population Assessment"},{"key":"2025102400413819000_CIT0025","doi-asserted-by":"publisher","DOI":"10.3886\/ICPSR36840.v23","author":"United States Department of Health and Human Services. National Institutes of Health. National Institute on Drug Abuse, United States Department of Health and Human Services","year":"2024","journal-title":"Food and Drug Administration. Center for Tobacco Products. Population Assessment of Tobacco and"},{"issue":"10","key":"2025102400413819000_CIT0026","doi-asserted-by":"publisher","first-page":"615","DOI":"10.1080\/15298669391355134","article-title":"Interpretation of urine results used to access chemical exposure with emphasis on creatinine adjustments: a review","volume":"54","author":"Boeniger","year":"1993","journal-title":"Am Ind Hyg Assoc J."},{"issue":"1","key":"2025102400413819000_CIT0027","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1080\/10937404.2013.864250","article-title":"Sources of Variability in Biomarker Concentrations","volume":"17","author":"Aylward","year":"2014","journal-title":"J Toxicol Environ Health B Crit Rev."},{"issue":"8","key":"2025102400413819000_CIT0028","doi-asserted-by":"publisher","first-page":"931","DOI":"10.1093\/ntr\/ntx166","article-title":"The relationship of E-cigarette use to cigarette quit attempts and cessation: insights from a large, nationally representative U.S. survey","volume":"20","author":"Levy","year":"2018","journal-title":"Nicotine Tob Res."},{"issue":"11","key":"2025102400413819000_CIT0029","doi-asserted-by":"publisher","first-page":"1106","DOI":"10.1001\/jama.2011.334","article-title":"Prevalence of heavy smoking in California and the United States, 1965-2007","volume":"305","author":"Pierce","year":"2011","journal-title":"JAMA."},{"issue":"41","key":"2025102400413819000_CIT0030","doi-asserted-by":"publisher","first-page":"917","DOI":"10.15585\/mmwr.mm7341a2","article-title":"Tobacco product use among middle and high school students - national youth tobacco survey, United States, 2024","volume":"73","author":"Jamal","year":"2024","journal-title":"MMWR Morb Mortal Wkly Rep."},{"issue":"8","key":"2025102400413819000_CIT0031","doi-asserted-by":"publisher","first-page":"814","DOI":"10.1093\/jat\/29.8.814","article-title":"Use of cotinine immunoassay test strips for preclassifying urine samples from smokers and nonsmokers prior to analysis by LC-MS-MS*","volume":"29","author":"Bernert","year":"2005","journal-title":"J Anal Toxicol."},{"issue":"20","key":"2025102400413819000_CIT0032","doi-asserted-by":"publisher","first-page":"4094","DOI":"10.1002\/sim.3222","article-title":"Multi-rule quality control for the age-related eye disease study","volume":"27","author":"Caudill","year":"2008","journal-title":"Stat Med."},{"issue":"September","key":"2025102400413819000_CIT0033","doi-asserted-by":"publisher","first-page":"290","DOI":"10.1016\/j.cca.2014.06.012","article-title":"A high-throughput robotic sample preparation system and HPLC-MS\/MS for measuring urinary anatabine, anabasine, nicotine and major nicotine metabolites","volume":"436","author":"Wei","year":"2014","journal-title":"Clin Chim Acta."},{"issue":"3","key":"2025102400413819000_CIT0034","doi-asserted-by":"publisher","first-page":"573","DOI":"10.1093\/ntr\/ntaa110","article-title":"Tobacco-Specific Nitrosamines (NNAL, NNN, NAT, and NAB) Exposures in the US Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014)","volume":"23","author":"Xia","year":"2021","journal-title":"Nicotine & Tobacco Research"},{"issue":"8","key":"2025102400413819000_CIT0035","doi-asserted-by":"publisher","first-page":"814","DOI":"10.1093\/jat\/29.8.814","article-title":"Use of continine immunoassay test strips for preclassifying urine samples from smokers and nonsmokers prior to analysis by LC-MS-MS","volume":"29","author":"Bernert","year":"2005","journal-title":"J Anal Toxicol."},{"issue":"6 Pt 1","key":"2025102400413819000_CIT0036","doi-asserted-by":"publisher","first-page":"1019","DOI":"10.1373\/49.6.1019","article-title":"Use of inductively coupled plasma mass spectrometry to measure urinary iodine in NHANES 2000: comparison with previous method","volume":"49","author":"Caldwell","year":"2003","journal-title":"Clin Chem."},{"issue":"1","key":"2025102400413819000_CIT0037","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1080\/1047322X.1990.10389587","article-title":"Estimation of average concentration in the presence of nondetectable values","volume":"5","author":"Hornung","year":"1990","journal-title":"Applied Occupational and Environmental Hygiene"},{"issue":"4","key":"2025102400413819000_CIT0038","doi-asserted-by":"publisher","first-page":"88","DOI":"10.3390\/toxics8040088","article-title":"Differences in exposure to nicotine, tobacco-specific nitrosamines, and volatile organic compounds among electronic cigarette users, tobacco smokers, and dual users from three countries","volume":"8","author":"Smith","year":"2020","journal-title":"Toxics"},{"issue":"3","key":"2025102400413819000_CIT0039","doi-asserted-by":"publisher","first-page":"EVIDoa2300229","DOI":"10.1056\/EVIDoa2300229","article-title":"Population-based disease odds for E-cigarettes and dual use versus cigarettes","volume":"3","author":"Glantz","year":"2024","journal-title":"NEJM Evid."},{"issue":"March","key":"2025102400413819000_CIT0040","doi-asserted-by":"publisher","first-page":"e62","DOI":"10.1136\/tc-2022-057405","article-title":"Trajectories of ENDS and cigarette use among dual users:","volume":"33","author":"Krishnan","year":"2022","journal-title":"Tob Control."},{"issue":"January 13","key":"2025102400413819000_CIT0041","doi-asserted-by":"publisher","DOI":"10.1136\/tc-2023-058554","article-title":"Hongying Daisy Dai. Biomarkers of metal exposure in adolescent e-cigarette users: correlations with vaping frequency and flavouring","author":"Andrew","year":"2025","journal-title":"Tob Control."},{"issue":"2","key":"2025102400413819000_CIT0042","doi-asserted-by":"publisher","first-page":"027010","DOI":"10.1289\/EHP2175","article-title":"Metal concentrations in e-cigarette liquid and aerosol samples: the contribution of metallic coils","volume":"126","author":"Olmedo","year":"2018","journal-title":"Environ Health Perspect."},{"issue":"1","key":"2025102400413819000_CIT0043","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1038\/s41598-024-59619-x","article-title":"Forecasting vaping health risks through neural network model prediction of flavour pyrolysis reactions","volume":"14","author":"Kishimoto","year":"2024","journal-title":"Sci Rep."}],"container-title":["Nicotine and Tobacco Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ntr\/advance-article-pdf\/doi\/10.1093\/ntr\/ntaf053\/62924113\/ntaf053.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ntr\/article-pdf\/27\/9\/1591\/62924113\/ntaf053.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ntr\/article-pdf\/27\/9\/1591\/62924113\/ntaf053.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,24]],"date-time":"2025-10-24T04:41:43Z","timestamp":1761280903000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ntr\/article\/27\/9\/1591\/8113057"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,15]]},"references-count":43,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,4,15]]},"published-print":{"date-parts":[[2025,8,22]]}},"URL":"https:\/\/doi.org\/10.1093\/ntr\/ntaf053","relation":{},"ISSN":["1469-994X"],"issn-type":[{"value":"1469-994X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2025,9]]},"published":{"date-parts":[[2025,4,15]]}}}