Why do the Japanese have the highest life expectancy in the world?

Why do the Japanese have the highest life expectancy in the world?

OVERVIEW

  • The Japanese have the highest life expectancy at birth among the G7 countries.
  • The higher life expectancy of the Japanese is mainly due to fewer deaths from ischemic heart disease, including myocardial infarction, and cancer (especially breast and prostate).
  • This exceptional longevity is explained by a low rate of obesity and a unique diet, characterized by a low consumption of red meat and a high consumption of fish and plant foods such as soybeans and tea.

Several diets are conducive to the maintenance of good health and to the prevention of cardiovascular disease, for example, the Mediterranean diet, the DASH diet (Dietary Approaches to Stop Hypertension), the vegetarian diet, and the Japanese diet. We often refer to the Mediterranean Diet in these pages, because it is well established scientifically that this diet is particularly beneficial for cardiovascular health. Knowing that the Japanese have the highest life expectancy among the G7 countries, the special diet in Japan has also captured the attention of experts and an informed public in recent years.

Japanese life expectancy
Among the G7 countries, Japan has the highest life expectancy at birth according to 2016 OECD data, particularly for women. Japanese men have a slightly higher life expectancy (81.1 years) than that of Canadian men (80.9 years), while the life expectancy of Japanese women (87.1 years) is significantly higher (2.4 years) than that of Canadian women (84.7 years). The healthy life expectancy of the Japanese, 74.8 years, is also higher than in Canada (73.2 years).

The higher life expectancy of Japanese people is mainly due to fewer deaths from ischemic heart disease and cancers, particularly breast and prostate cancer. This low mortality is mainly attributable to a low rate of obesity, low consumption of red meat, and high consumption of fish and plant foods such as soybeans and tea. In Japan, the obesity rate is low (4.8% for men and 3.7% for women). By comparison, in Canada 24.6% of adult men and 26.2% of adult women were obese (BMI ≥ 30) in 2016. Obesity is an important risk factor for both ischemic heart disease and several types of cancers.

Yet in the early 1960s, Japanese life expectancy was the lowest of any G7 country, mainly due to high mortality from cerebrovascular disease and stomach cancer. The decrease in salt and salty food intake is partly responsible for the decrease in mortality from cerebrovascular disease and stomach cancer. The Japanese consumed an average of 14.5 g of salt/day in 1973 and probably more before that. They eat less salt these days (9.5 g/day in 2017), but it’s still too much. Canadians now consume on average about 7 g of salt/day (2.76 g of sodium/day), almost double the intake recommended by Health Canada.

The Japanese diet
Compared to Canadians, the French, Italians and Americans, the Japanese consume much less meat (especially beef), dairy products, sugar and sweeteners, fruits and potatoes, but much more fish and seafood, rice, soybeans and tea (Table 1). In 2017, the Japanese consumed an average of 2,697 kilocalories per day according to the FAO, significantly less than in Canada (3492 kcal per day), France (3558 kcal per day), Italy (3522 kcal per day), and the United States (3766 kcal per day).

Table 1. Food supply quantity (kg/capita/year) in selected countries in 2013a.

              aAdapted from Tsugane, 2020. FAO data: FAOSTAT (Food and agriculture data) (http://www.fao.org/).

Less red meat, more fish and seafood
The Japanese eat on average almost half as much meat as Canadians (46% less), but twice as much fish and seafood. This considerable difference translates into a reduced dietary intake of saturated fatty acids, which is associated with a lower risk of ischemic heart disease, but an increased risk of stroke. On the contrary, dietary intake of omega-3 fatty acids found in fish and seafood is associated with a reduced risk of ischemic heart disease. The lower consumption of red meat and higher consumption of fish and seafood by the Japanese could therefore explain the lower mortality from ischemic heart disease and the higher mortality from cerebrovascular disease in Japan. Experts believe that the decline in death from cerebrovascular disease is associated with changes in the Japanese diet, specifically increased consumption of animal products and dairy products, and consequently of saturated fat and calcium (a consumption which remains moderate), combined with a decrease in salt consumption. Indeed, contrary to what is observed in the West, the consumption of saturated fat in Japan is associated with a reduction in the risk of hemorrhagic stroke and to a lesser extent of ischemic stroke, according to a meta-analysis of prospective studies. The cause of this difference is not known, but it could be attributable to genetic susceptibility or confounding factors according to the authors of the meta-analysis.

Soybeans
Soy is a food mainly consumed in Asia, including Japan where it is consumed as is after cooking (edamame) and especially in processed form, by fermentation (soy sauce, miso paste, nattō) or by coagulation of soy milk (tofu). It is an important source of isoflavones, molecules that have anticancer properties and are beneficial for good cardiovascular health. Consumption of isoflavones by Asians has been linked to a lower risk of breast and prostate cancer (see our article on the subject).

Sugar
The Japanese consume relatively few sugars and starches, which partly explains the low prevalence of obesity-associated diseases such as ischemic heart disease and breast cancer.

Green tea
The Japanese generally consume green tea with no added sugar. Prospective studies from Japan show that green tea consumption is associated with a lower risk of all-cause mortality and cardiac death.

Westernization of Japanese eating habits
The westernization of the Japanese diet after World War II allowed the inhabitants of this country to be healthier and to reduce mortality caused by infectious diseases, pneumonia and cerebrovascular diseases, thereby considerably increasing their life expectancy. A survey of the eating habits of 88,527 Japanese from 2003 to 2015 indicates that this westernization continues. Based on the daily consumption of 31 food groups, the researchers identified three main types of eating habits:

1- Plant foods and fish
High intakes of vegetables, fruits, legumes, potatoes, mushrooms, seaweed, pickled vegetables, rice, fish, sugar, salt-based seasonings and tea.

2- Bread and dairy
High intakes of bread, dairy products, fruits and sugar. Low intake of rice.

3- Animal foods and oils
High intakes of red and processed meat, eggs, vegetable oils.

A downward trend in the “plant foods and fish” group (the staple of the traditional Japanese diet or washoku) was observed in all age groups. An increase in the “bread and dairy” group was observed in the 50–64 and ≥65 years age groups, but not among the youngest. For the “animal foods and oils” group, an increasing trend was observed during the thirteen years of the study in all age groups except the youngest (20–34 years). The Japanese are eating more and more like Westerners. Will this have an adverse effect on their health and life expectancy? It is too early to know, only the next few decades will tell.

Contribution of genes and lifestyle to the health of the Japanese
Some risk factors for cardiovascular disease and cancer are hereditary, while others are associated with lifestyle (diet, smoking, exercise, etc.). At the turn of the 20th century, there was significant Japanese immigration to the United States (especially California and Hawaii) and South America (Brazil, Peru). After a few generations, the descendants of Japanese migrants adopted the way of life of the host countries. While Japan has one of the lowest incidences of cardiovascular disease in the world, this incidence doubled among the Japanese who migrated to Hawaii and quadrupled among those who chose to live in California according to a 1975 study. What is surprising is that this increase has been observed regardless of blood pressure or cholesterol levels, and seems rather directly related to the abandonment of the traditional Japanese way of life by migrants.

Since the 1970s, the average cholesterol level of the Japanese has nonetheless increased, but despite this and the high rate of smoking in this country, the incidence of coronary heart disease remains substantially lower in Japan than in the West. To better understand these differences, a 2003 study compared the risk factors and diets of Japanese living in Japan with third- and fourth-generation Japanese migrants living in Hawaii in the United States. Men’s blood pressure was significantly higher among Japanese than among Japanese-Americans, while there was no significant difference for women. Far fewer Japanese were treated for hypertension than in Hawaii. More Japanese people (especially men) smoked than Japanese-Americans. Body mass index, blood levels of LDL cholesterol, total cholesterol, glycated hemoglobin (an indicator for diabetes), and fibrinogen (a marker of inflammation) were significantly lower in Japan than in Hawaii. HDL cholesterol (the “good” cholesterol) was higher in the Japanese than in the Japanese-Americans. The dietary intake of total fat and saturated fatty acids (harmful to cardiovascular health) was lower in Japan than in Hawaii. In contrast, the intake of polyunsaturated fatty acids and omega-3 fatty acids (beneficial for good cardiovascular health) was higher in Japan than in Hawaii. These differences may partly explain the lower incidence of coronary heart disease in Japan than in Western industrialized countries.

In other words, even if these migrants have the same basic risk as their compatriots who have remained in the country of origin (age, sex and heredity), the simple fact of adopting the lifestyle of their host country is enough to significantly increase their risk of cardiovascular disease.

Although the Japanese diet is different from those of Western countries, it has similar characteristics to the Mediterranean diet. Why not prepare delicious Japanese soy dishes from time to time (for example, tofu, edamame, miso soup), drink green tea, eat less meat, sugar and starch and more fish? Not only will your meals be more varied, but you could enjoy the health benefits of the Japanese diet.

Reducing calorie intake by eating more plants

Reducing calorie intake by eating more plants

OVERVIEW

  • Twenty volunteers were fed a low-fat or low-carbohydrate diet in turn for two weeks.
  • Participants on the low-fat diet consumed an average of nearly 700 fewer calories per day than with the low-carbohydrate diet, a decrease correlated with a greater loss of body fat.
  • Compared to the low-carbohydrate diet, the low-fat diet also led to lower cholesterol levels, reduced chronic inflammation, and lowered heart rate and blood pressure.
  • Overall, these results suggest that a diet mainly composed of plants and low in fat is optimal for cardiovascular health, both for its superiority in reducing calorie intake and for its positive impact on several risk factors for cardiovascular disease.

It is estimated that there are currently around 2 billion overweight people in the world, including 600 million who are obese. These statistics are truly alarming because it is clearly established that excess fat promotes the development of several diseases that decrease healthy life expectancy, including cardiovascular disease, type 2 diabetes, and several types of cancer. Identifying the factors responsible for this high prevalence of overweight and the possible ways to reverse this trend as quickly as possible is therefore essential to improve the health of the population and avoid unsustainable pressures on public health systems in the near future.

Energy imbalance
The root cause of overweight, and obesity in particular, is a calorie intake that exceeds the body’s energy needs. To lose weight, therefore, it is essentially a matter of restoring the balance between the calories ingested and the calories expended.

It might seem simple in theory, but in practice most people find it extremely difficult to lose weight. On the one hand, it is much easier to gain weight than to lose weight. During evolution, we have had to deal with periods of prolonged food shortages (and even starvation, in some cases) and our metabolism has adapted to these deficiencies by becoming extremely efficient at accumulating and conserving energy in the form of fat. On the other hand, the environment in which we currently live strongly encourages overconsumption of food. We are literally overwhelmed by an endless variety of attractive food products, which are often inexpensive, easily accessible, and promoted by very aggressive marketing that encourages their consumption. The current epidemic of overweight and obesity thus reflects our biological predisposition to accumulate reserves in the form of fat, a predisposition that is exacerbated by the obesogenic environment that surrounds us.

Eating less to restore balance
The body’s innate tendency to keep energy stored in reserve as fat makes it extremely difficult to lose weight by “burning” those excess calories by increasing the level of physical activity. For example, a person who eats a simple piece of sugar pie (400 calories) will have to walk about 6.5 km to completely burn off those calories, which, of course, is difficult to do on a daily basis. This does not mean that exercise is completely useless for weight loss. Research in recent years shows that exercise can specifically target certain fat stores, especially in the abdominal area. Studies also show that regular physical activity is very important for long-term maintenance of the weight lost from a low-calorie diet. However, there is no doubt that it is first and foremost the calories consumed that are the determining factors in weight gain. Moreover, contrary to what one might think, levels of physical activity have hardly changed for the last thirty years in industrialized countries, and the phenomenal increase in the number of overweight people is therefore mainly a consequence of overconsumption of food. Exercise is essential for the prevention of all chronic diseases and for the maintenance of general good health, but its role in weight loss is relatively minor. For overweight people, the only realistic way to lose weight significantly, and especially to maintain these losses over prolonged periods, is thus to reduce calorie intake.

Less sugar or less fat?
How do we get there? First, it’s important to realize that the surge in the number of overweight people has coincided with a greater availability of foods high in sugar or fat (and sometimes both). All countries in the world, without exception, that have adopted this type of diet have seen their overweight rates skyrocket, so it is likely that this change in eating habits plays a major role in the current obesity epidemic.

However, the respective contributions of sugar and fat to this increase in caloric intake and overweight are still the subjectof vigorous debate:

1) On the one hand, it has been proposed that foods high in fat are particularly obesogenic, since fats are twice as high in calories as carbohydrates, are less effective in causing a feeling of satiety, and improve the organoleptic properties of foods, which generally encourages (often unconscious) overconsumption of food. Therefore, the best way to avoid overeating and becoming overweight would be to reduce the total fat intake (especially saturated fat due to its negative impact on LDL-cholesterol levels) and replace it with complex carbohydrates (vegetables, legumes, whole-grain cereals). This is colloquially called the low-fat approach, advocated for example by the Ornish diet.

2) On the other hand, the exact opposite is proposed, i.e. that it would be mainly carbohydrates that would contribute to overconsumption of food and to the increase in the incidence of obesity. According to this model, carbohydrates in foods in the form of free sugars or refined flours cause insulin levels to rise markedly, causing massive energy storage in adipose tissue. As a result, fewer calories remain available in the circulation for use by the rest of the body, causing increased appetite and overeating to compensate for this lack. In other words, it wouldn’t be because we eat too much that we get fat, but rather because we are too fat we eat too much.

3) By preventing excessive fluctuations in insulin levels, a diet low in carbohydrates would thus limit the anabolic effect of this hormone and, therefore, prevent overeating and the accumulation of excess fat.

Less fat on the menu, fewer calories ingested
To compare the impact of low-carb and low-fat diets on calorie intake, Dr. Kevin Hall’s group (NIH) recruited 20 volunteers who were fed each of these diets in turn for two weeks. The strength of this type of cross-study is that each participant consumes both types of diets and that their effects can therefore be compared directly on the same person.

As shown in Figure 1, the two diets studied were completely opposite of each other, with 75% of the calories in the low-fat (LF) diet coming from carbohydrates versus only 10% from fat, while in the low-carb (LC) diet, 75% of calories were in the form of fat, compared to only 10% from carbohydrates. The LF diet under study consisted exclusively of foods of plant origin (fruits, vegetables, legumes, root vegetables, soy products, whole grains, etc.), while the LC diet contained mainly (82%) animal foods (meat, poultry, fish, eggs, dairy products).

Figure 1. Comparison of the amounts of carbohydrates, fats and proteins present in the low-carbohydrate (LC) and low-fat (LF) diets consumed by study participants. Adapted from Hall et al. (2021).

The study shows that there is indeed a big difference between the two types of diets in the number of calories consumed by participants (Figure 2). Over a two-week period, participants who ate an LF (low-fat) diet consumed an average of nearly 700 calories (kcal) per day less than an LC (low-carbohydrate) diet. This difference in calorie intake is observed for all meals, both at breakfast (240 calories less for the LF diet), at lunch (143 calories less), at dinner (195 calories less), and during snacks taken between meals (128 calories less). This decrease is not caused by a difference in the appreciation of the two diets by the participants, as parallel analyses did not find any difference in the level of appetite of the participants, nor in the degree of satiety and satisfaction generated by the consumption of either diet. However, the LF diet was composed exclusively of plant-based foods and therefore much richer in non-digestible fibres (60 g per day compared to only 20 g for the LC diet), which greatly reduce the energy density of meals (quantity of calories per g of food) compared to the high-fat LC diet. It is therefore very likely that this difference in energy density contributes to the lower calorie intake observed for the low-fat diet.

Overall, these results indicate that a diet consisting of plants, and thus low in fat and high in complex carbohydrates, is more effective than a diet consisting mainly of animal products, high in fat and low in carbohydrates, to limit calorie intake.

Figure 2. Comparison of the daily calorie intake of participants on a low-carbohydrate (LC) or low-fat (LF) diet. From Hall et al. (2021).

Weight loss
Despite the significant difference in calorie intake observed between the two diets, their respective impact on short-term weight loss is more nuanced. At first glance, the LC diet appeared to be more effective than the LF diet in causing rapid weight loss, with about 1 kg lost on average in the first week and almost 2 kg after two weeks, compared to only 1 kg after two weeks of the LF diet (Figure 3). However, further analysis revealed that the weight loss caused by the LC diet was mainly in the form of lean mass (protein, water, glycogen), while this diet had no significant impact on fat loss during this period. Conversely, the LF diet had no effect on this lean body mass, but did cause a significant decrease in body fat, to around 1 kg after two weeks. In other words, only the LF diet caused a loss of body fat during the study period, which strongly suggests that the decrease in calorie intake made possible by this type of diet may facilitate the maintenance of astable body weight and could even promote weight loss in overweight people.

Figure 3. Comparison of changes in body weight (top), lean mass (middle), and body fat (bottom) caused by low-carbohydrate and low-fat diets. From Hall et al. (2021).

Cardiovascular risk factors
In addition to promoting lower calorie intake and fat loss, the LF diet also appears to be superior to the LC diet in terms of its impact on several cardiovascular risk factors (Table 1):

Cholesterol. It is well established that LDL cholesterol levels increase in response to a high intake of saturated fat (see our article on the issue). It is therefore not surprising that the LF diet, which contains only 2% of all calories as saturated fat, causes a significant decrease in cholesterol, both in terms of total cholesterol and LDL cholesterol. At first glance, the high-fat LC diet (containing 30% of the daily calorie intake as saturated fat) does not appear to have a major effect on LDL cholesterol; however, it should be noted that this diet significantly modifies the distribution of LDL cholesterol particles, in particular with a significant increase in small and dense LDL particles. Several studies have reported that these small, dense LDL particles infiltrate artery walls more easily and also appear to oxidize more easily, two key events in the development and progression of atherosclerosis. In sum, just two weeks of a high-fat LC diet was enough to significantly (and negatively) alter the atherogenic profile of participants, which may raise doubts about the long-term effects of this type of diet on cardiovascular health.

Table 1. Variations in certain risk factors for cardiovascular disease following a diet low in carbohydrates or low in fat. From Hall et al. (2021).

Branched-chain amino acids. Several recent studies have shown a very clear association between blood levels of branched-chain amino acids (leucine, isoleucine and valine) and an increased risk of metabolic syndrome and type 2 diabetes, two very important risk factors for cardiovascular diseases. In this sense, it is very interesting to note that the levels of these amino acids are almost twice as high after two weeks of the LC diet compared to the LF diet, suggesting a positive effect of a diet rich in plants and poor in fats in the prevention of these disorders.

Inflammation. Chronic inflammation is actively involved in the formation and progression of plaques that form on the lining of the arteries and can lead to the development of cardiovascular events such as myocardial infarction and stroke. Clinically, this level of inflammation is often determined by measuring levels of high-sensitivity C-reactive protein (hsCRP), a protein made by the liver and released into the blood in response to inflammatory conditions. As shown in Table 1, the LF diet significantly decreases the levels of this inflammatory marker, another positive effect that argues in favour of a plant-rich diet for the prevention of cardiovascular disease.

In addition to these laboratory data, the researchers noted that participants who were fed the LF diet had a slower heart rate (73 vs. 77 beats/min) as well as lower blood pressure (112/67 vs. 116/69 mm Hg) than observed following the LC diet. In the latter case, this difference could be related, at least in part, to the much higher sodium consumption in the LC diet compared to the LF diet (5938 vs. 3725 mg/day).

All of these results confirm the superiority of a diet mainly composed of plants on all the factors involved in cardiovascular health, whether in terms of lipid profile, chronic inflammation, or adequate control of calorie intake necessary to maintain body weight.

Electronic cigarettes cause much less inflammation than tobacco

Electronic cigarettes cause much less inflammation than tobacco

OVERVIEW

  • Cigarette smoke causes chronic inflammation that significantly increases the risk of lung and cardiovascular disease.
  • Two recent studies show that this inflammation can be considerably reduced by replacing cigarettes with e-cigarettes.
  • Smokers can therefore drastically reduce the damage caused by cigarette smoke and the risk of smoking-related illnesses by using e-cigarettes as a source of nicotine.

It is now well established that smokers have a reduced life expectancy of around 10 years compared to non-smokers. This dramatic increase in the risk of premature mortality is due to the repeated exposure of smokers to the thousands of toxic and carcinogenic substances that are generated during the combustion of tobacco leaves (polycyclic aromatic hydrocarbons and nitrosamines, among others). For example, it is estimated that each pack of cigarettes contains enough carcinogenic compounds to cause two mutations in the DNA of lung cells, so decades of smoking results in the accumulation of several thousand of these mutations and dramatically increases (about 40 times) the risk of lung cancer.

Pro-inflammatory smoke
Another factor that contributes to the harmfulness of tobacco is the chronic inflammation caused by the many toxic compounds found in cigarette smoke. Locally, this inflammation damages cells in the airways and greatly increases the risk of developing chronic obstructive pulmonary disease (e.g. emphysema). But the damage caused by this inflammation is not limited to the lungs. Following inhalation of cigarette smoke, the toxic compounds rapidly diffuse into the pulmonary capillaries and can then spread throughout the body via the bloodstream. A climate of generalized chronic inflammation is then created, characterized by an increase in several inflammatory markers (IL-6, CRP, ICAM) and the recruitment of immune cells to the surface of blood vessels, two phenomena that contribute to the development of atherosclerosis.

The blood vessels that supply the heart (coronary arteries) are particularly vulnerable to this inflammation. Since the heart is closely associated with the lungs, it is the first organ to receive blood that has been in contact with cigarette smoke and is therefore necessarily exposed to higher concentrations of toxic compounds.

The consequences of this proximity are disastrous. Studies show that people who smoke a pack a day have a 5 times higher risk of myocardial infarction compared to those who have never smoked, and smoking is estimated to be responsible for about 20% of all coronary heart disease deaths. So, even though we mainly talk about the major impact of tobacco on the risk of suffering from lung cancer, we must not forget that cardiovascular diseases remain the main cause of death associated with smoking. Of all the actions a person can take to improve their cardiovascular health (and overall health), quitting smoking is by far the most important.

Reversible damage
The good news is that this damage of smoking on cardiovascular health can be reversed by quitting. Studies show that former smokers see their risk of cardiovascular accident decrease by 40% in the first five years after quitting and becomes similar to that of non-smokers after 10–15 years. Smoking cessation is beneficial at any age, but is particularly effective before the age of 40, with a 90% reduction in the risk of premature death from smoking.

Quitting smoking is difficult, with only 5% of people able to remain smoke-free after one year. However, several recent data show that this smoking cessation success rate can be considerably increased among smokers who opt for e-cigarettes. For example, a randomized clinical trial recently showed that e-cigarettes can double the effectiveness of smoking cessation compared to traditional approaches based on nicotine replacement therapy. A Cochrane review of 50 studies (including 26 randomized trials) with a total of 12,430 participants comes to a similar conclusion.

Reducing damage
In addition to facilitating smoking cessation in the longer term, adopting e-cigarettes also has the advantage of immediately reducing the damage caused by tobacco. Remember that in an e-cigarette, a nicotine solution is heated to 80°C (compared to temperatures around 900°C in a cigarette), and therefore the vapour generated does not contain carbon monoxide, nor the thousands of toxic combustion products found in cigarette smoke. According to a recent study by the Institut Pasteur, the vapour emanating from e-cigarettes contains less than 1% of the toxins present in cigarette smoke, and consequently substantially reduce smokers’ exposure to these toxic compounds (see our article on this subject).

Two recent studies show that this drastic decrease in the amount of toxic compounds in e-cigarette vapour correlates with a significant decrease in inflammation normally observed in response to cigarette smoke. In the first of these studies, the researchers compared the levels of different inflammatory markers (hsCRP, IL-6, sICAM) or oxidative stress (urinary 8-isoprostane) present in non-smokers, vapers, cigarette smokers, and mixed users (vapers and smokers). As shown in Figure 1, while smoking causes a significant increase in the levels of all markers examined, these increases are much smaller, and in some cases (IL-6) even completely abolished, among exclusive e-cigarette users. Replacing tobacco cigarettes with an e-cigarette can therefore substantially decrease the inflammatory response and, in turn, reduce the risk of cardiovascular disease. However, the study clearly shows that this reduction in inflammation is not at all observed in vapers who continue to smoke cigarettes at the same time. To truly reduce the damage caused by smoking, e-cigarettes must therefore completely replace cigarettes and not simply serve to reduce the number of cigarettes smoked in a day.

Figure 1. Change in the levels of different markers of inflammation and oxidative stress in vapers and smokers. From Stokes et al. (2020). hsCRP: high sensitivity C-reactive protein; IL-6: interleukin-6; sICAM: soluble intercellular adhesion molecule.

The other study looked at the impact of e-cigarettes on the expression of inflammatory proteins by monocytes, a class of white blood cells involved in the innate immune response. Over-activation of these cells (by toxic compounds like cigarette smoke, for example) has been shown to trigger an inflammatory response that plays an important role in the initiation and progression of atherosclerosis.

Using blood samples taken from non-smokers, smokers, and vapers, the researchers examined by flow cytometry the profiles of inflammatory proteins (caspase-1, IL-6 receptor, TLR4) present in circulating monocytes in each category of volunteers. Unsurprisingly, they noted that the expression of all of these inflammatory proteins was higher in smokers, about 4 times higher on average than in non-smokers. However, this inflammatory signature was completely absent in vapers, suggesting once again that the elimination of cigarettes in favour of e-cigarettes leads to concrete health benefits for smokers. This is consistent with a recent randomized controlled trial that showed that the transition of smokers to e-cigarettes is accompanied by a rapid improvement (in just 1 month) in the health of the blood vessels.

This study shows once again how e-cigarettes allow smokers to significantly reduce their exposure to the many toxic substances in cigarette smoke and are therefore an extremely useful tool in the fight against diseases caused by smoking.

Effects of cold on cardiovascular health

Effects of cold on cardiovascular health

OVERVIEW

  • Exposure to cold causes a contraction of blood vessels as well as an increase in blood pressure, heart rate, and the work of the heart muscle.
  • The combination of cold and exercise further increases stress on the cardiovascular system.
  • Cold temperatures are associated with increased cardiac symptoms (angina, arrhythmias) and an increased incidence of myocardial infarction and sudden cardiac death.
  • Patients with coronary artery disease should limit exposure to cold and dress warmly and cover their face when exercising.

Can the sometimes biting cold of our winters affect our overall health and our cardiovascular health in particular? For an exhaustive review of the literature on the effects of cold on health in general, see the summary report (in French only) recently published by the Institut national de santé publique du Québec (INSPQ). In this article, we will focus on the main effects of cold on the cardiovascular system and more specifically on the health of people with cardiovascular disease.

Brief and prolonged exposure to cold both affect the cardiovascular system, and exercise in cold weather further increases stress on the heart and arteries. Numerous epidemiological studies have shown that cardiovascular disease and mortality increase when the ambient temperature is cold and during cold spells. The winter season is associated with a greater number of cardiac symptoms (angina, arrhythmias) and cardiovascular events such as hypertensive crisis, deep venous thrombosis, pulmonary embolism, aortic ruptures and dissections, stroke, intracerebral hemorrhage, heart failure, atrial fibrillation, ventricular arrhythmia, angina pectoris, acute myocardial infarction, and sudden cardiac death.

Mortality from cold
Globally, more temperature-related deaths were caused by cold (7.29%) than heat (0.42%). For Canada, 4.46% of deaths were attributable to cold (2.54% for Montreal), and 0.54% to heat (0.68% for Montreal).

Intuition may lead us to believe that it is during periods of extreme cold that more adverse health effects occur, but the reality is quite different. According to a study that analyzed 74,225,200 deaths that occurred between 1985 and 2012 in 13 large countries on 5 continents, extreme temperatures (cold or hot) accounted for only 0.86% of all deaths, while the majority of cold-related deaths occurred at moderately cold temperatures (6.66%).

Acute effects of cold on the cardiovascular system of healthy people

Blood pressure. The drop in skin temperature upon exposure to cold is detected by skin thermoreceptors that stimulate the sympathetic nervous system and induce a vasoconstriction reflex (decrease in the diameter of the blood vessels). This peripheral vasoconstriction prevents heat loss from the surface of the body and has the effect of increasing systolic (5–30 mmHg) and diastolic (5–15 mmHg) blood pressure.

Heart rate. It is not greatly affected by exposure of the body to cold air, but it increases rapidly when, for example, the hand is dipped in ice water (“cold test” used to make certain diagnoses, such as Raynaud’s disease) or when very cold air is inhaled. Cold air usually causes a slight increase in heart rate in the range of 5 to 10 beats per minute.

Risk of atheromatous plaque rupture?
Post-mortem studies have shown that rupture of atheroma plaques (deposits of lipids on the lining of the arteries) is the immediate cause of over 75% of acute myocardial infarctions. Could cold stress promote the rupture of atheromatous plaques? In a laboratory study, mice exposed to cold in a cold room (4°C) for 8 weeks saw their blood LDL cholesterol level and the number of plaques increase compared to mice in the control group (room at 30°C). Furthermore, it is known that exposure to cold induces aggregation of platelets in vitro and increases coagulation factors in vivo in patients during colder days (< 20°C) compared to warmer days (> 20°C). Combined, these cold effects could help promote plaque rupture, but to date no study has been able to demonstrate this.

Risk of cardiac arrhythmias
Arrhythmias are a common cause of sudden cardiac death. Even in healthy volunteers, the simple act of dipping a hand in cold water while holding the breath can cause cardiac arrhythmias (nodal and supraventricular tachycardias). Could cold promote sudden death in people at risk for or with heart disease? Since arrhythmias cannot be detected post-mortem, it is very difficult to prove such a hypothesis. If it turns out that exposure to cold air can promote arrhythmias, people with coronary artery disease may be vulnerable to the cold since the arrhythmia would amplify the oxygenated blood deficit that reaches the heart muscle.

Effects of cold combined with exercise
Both cold and exercise individually increase the heart’s demand for oxygen, and the combination of the two stresses has an additive effect on this demand (see these two review articles, here and here). Exercising in the cold therefore results in an increase in systolic and diastolic blood pressure as well as in the “double product” (heart rate x blood pressure), a marker of cardiac work. The increased demand for oxygen by the heart muscle caused by cold weather and exercise increases blood flow to the coronary arteries that supply the heart. The rate of coronary blood flow increases in response to cold and exercise combined compared to exercise alone, but this increase is mitigated, especially in older people. Therefore, it appears that cold causes a relative lag between the oxygen demand from the myocardium and the oxygenated blood supply during exercise.

In a study carried out by our research team, we exposed 24 coronary patients with stable angina to various experimental conditions in a cold room at – 8°C, specifically a stress test with electrocardiogram (ECG) in cold without antianginal medication and an ECG at + 20°C. We then repeated these two ECGs after taking one drug (propranolol) that slows the heart rate, and then another drug (diltiazem) that causes dilation of the coronary arteries. The results showed that the cold caused mild to moderate ischemia (lack of blood supply) to the myocardium in only 1/3 of the patients. When ECG was done with medication, this effect was completely reversed. The two drugs have been shown to be equally effective in reversing this ischemia. The conclusion: cold had only a modest effect in 1/3 of patients and antianginal drugs are as effective in cold (- 8°C) as at + 20°C.

In another study in the same type of patients, we compared the effects of an ECG at – 20°C with an ECG at + 20°C. The results showed that at this very cold temperature, all patients presented with angina and earlier ischemia.

Hypertension
The prevalence of hypertension is higher in cold regions or during winter. Cold winters increase the severity of hypertension and the risk of cardiovascular events such as myocardial infarction and stroke in people with hypertension.

Heart failure
The heart of patients with heart failure is not able to pump enough blood to maintain the blood flow necessary to meet the body’s needs. Only a few studies have looked at the effects of cold on heart failure. Patients with heart failure do not have much leeway when the heart’s workload increases in cold weather or when they need to exert sustained physical effort. Cold combined with exercise further decreases the performance of people with heart failure. For example, in a study we conducted at the Montreal Heart Institute, cold reduced exercise time by 21% in people with heart failure. In the same study, the use of beta-blocker class antihypertensive drugs (metoprolol or carvedilol) significantly increased exercise time and reduced the impact of cold exposure on the functional capacity of patients. Another of our studies indicates that treatment with an antihypertensive drug from the class of angiotensin converting enzyme inhibitors, lisinopril, also mitigates the impact of cold on the ability to exercise in patients with heart failure.

Cold, exercise and coronary heart disease
It is rather unlikely that the cold alone could cause an increase in the work of the heart muscle large enough to cause a heart attack. Cold stress increases the work of the heart muscle and therefore the blood supply to the heart in healthy people, but in coronary patients there is usually a reduction in blood flow to the coronary arteries. The combination of cold and exercise puts coronary patients at risk of cardiac ischemia (lack of oxygen to the heart) much earlier in their workout than in warm or temperate weather. For this reason, people with coronary artery disease should limit exposure to cold and wear clothes that keep them warm and cover their face (significant heat loss in this part of the body) when working out outdoors in cold weather. In addition, the exercise tolerance of people with coronary heart disease will be reduced in cold weather. It is strongly recommended that coronary heart patients do indoor warm-up exercises before going out to exercise outdoors in cold weather.

The importance of properly controlling your blood pressure

The importance of properly controlling your blood pressure

OVERVIEW

  • Hypertension is the main risk factor for cardiovascular disease and is responsible for 20% of deaths worldwide.
  • Early hypertension, before the age of 45, is associated with an increased risk of cardiovascular disease, cognitive decline and premature mortality.
  • Adopting an overall healthy lifestyle (normal weight, not smoking, regular physical activity, moderate alcohol consumption, and a good diet including sodium reduction) remains the best way to maintain adequate blood pressure.

According to the latest data from the Global Burden of Disease Study 2019, excessively high blood pressure was responsible for 10.8 million deaths worldwide in 2019, or 19.2% of all deaths recorded. This devastating impact is a direct consequence of the enormous damage caused by hypertension on the cardiovascular system. Indeed, a very large number of studies have clearly shown that excessive blood pressure, above 130/80 mm Hg (see box for a better understanding of blood pressure values), is closely linked to a significant increased risk of coronary heart disease and stroke.

 

Systolic and diastolic

It is important to remember that blood pressure is always expressed in the form of two values, namely systolic pressure and diastolic pressure. Systolic pressure is the pressure of the blood ejected by the left ventricle during the contraction of the heart (systole), while diastolic pressure is that measured between two beats, during the filling of the heart (diastole). To measure both pressures, the arterial circulation in the arm is completely blocked using an inflatable cuff, then the cuff pressure is allowed to gradually decrease until blood begins to flow back into the artery. This is the systolic pressure. By continuing to decrease the swelling of the cuff, we then arrive at a pressure from which there is no longer any obstacle to the passage of blood in the artery, even when the heart is filling. This is the diastolic pressure. A blood pressure value of 120/80 mm Hg, for example, therefore represents the ratio of systolic (120 mm Hg) and diastolic (80 mm Hg) pressures.

As shown in Figure 1, this risk of dying prematurely from coronary heart disease is moderate up to a systolic pressure of 130 mm Hg or a diastolic pressure of 90 mm Hg, but increases rapidly thereafter to almost 4 times for pressures equal to or greater than 150/98 mm Hg. This impact of hypertension is even more pronounced for stroke, with an 8 times higher risk of mortality for people with systolic pressure above 150 mm Hg and 4 times higher for a diastolic pressure greater than 98 mm Hg (Figure 1, bottom graph). Consequently, high blood pressure is by far the main risk factor for stroke, being responsible for about half of the mortality associated with this disease.


Figure 1. Association between blood pressure levels and the risk of death from coronary heart disease or stroke. From Stamler et al. (1993).

Early hypertension
Blood pressure tends to increase with aging as blood vessels become thicker and less elastic over time (blood circulates less easily and creates greater mechanical stress on the vessel wall). On the other hand, age is not the only risk factor for high blood pressure: sedentary lifestyle, poor diet (too much sodium intake, in particular), and excess body weight are all lifestyle factors that promote the development of hypertension, including in younger people.

In industrialized countries, these poor lifestyle habits are very common and contribute to a fairly high prevalence of hypertensive people, even among young adults. In Canada, for example, as many as 15% of adults aged 20–39 and 39% of those aged 40–59 have blood pressure above 130/80 mm Hg (Figure 2).


Figure 2. Prevalence of hypertension in the Canadian population. Hypertension is defined as systolic pressure ≥ 130 mm Hg or diastolic pressure ≥ 80 mm Hg, according to the 2017 criteria of the American College of Cardiology and the American Heart Association. The data are from Statistics Canada.

This proportion of young adults with hypertension is lower than that observed in older people (three in four people aged 70 and over have hypertension), but it can nevertheless have major repercussions on the health of these people in the longer term. Several recent studies indicate that it is not only hypertension per se that represents a risk factor for cardiovascular disease, but also the length of time a person is exposed to these high blood pressures. For example, a recent study reported that onset of hypertension before the age of 45 doubles the risk of cardiovascular disease and premature death, while onset of hypertension later in life (55 years and older) has a much less pronounced impact (Figure 3). These findings are consistent with studies showing that early hypertension is associated with an increased risk of cardiovascular mortality and damage to target organs (heart, kidneys, brain). In the case of the brain, high blood pressure in young adults has been reported to be associated with an increased risk of cognitive decline at older ages. Conversely, a recent meta-analysis suggests that a reduction in blood pressure with the help of antihypertensive drugs is associated with a lower risk of dementia or reduced cognitive function.

Figure 3. Change in risk of cardiovascular disease (red) or death from all causes (blue) depending on the age at which hypertension begins. Adapted from Wang et al. (2020).

Early hypertension should therefore be considered an important risk factor, and young adults can benefit from managingtheir blood pressure as early as possible, before this excessively high blood pressure causes irreparable damage.

The study of barbershops
In African-American culture, barbershops are gathering places that play a very important role in community cohesion. For health professionals, frequent attendance at these barbershops also represents a golden opportunity to regularly meet Black men to raise their awareness of certain health problems that disproportionately affect them. This is particularly the case with hypertension: African American men 20 years and older have one of the highest prevalence of high blood pressure in the world, with as many as 59% of them being hypertensive. Also, compared to whites, Black men develop high blood pressure earlier in their lives and this pressure is on average much higher.

A recent study indicates that barbershops may raise awareness among African Americans about the importance of controlling their blood pressure and promoting the treatment of hypertension. In this study, researchers recruited 319 African Americans aged 35 to 79 who were hypertensive (average blood pressure approximately 153 mm Hg) and who were regular barbershop customers. Participants were randomly assigned to two groups: 1) an intervention group, in which clients were encouraged to see, in the barbershops, pharmacists specially trained to diagnose and treat hypertension and 2) a control group, in which barbers suggested that clients make lifestyle changes and seek medical attention. In the intervention group, pharmacists met regularly with clients during their barbershop visits, prescribed antihypertensive drugs, and monitored their blood pressure.

After only 6 months, the results obtained were nothing short of spectacular: the blood pressure of the intervention group fell by 27 mm Hg (to reach 125.8 mm Hg on average), compared to only 9.3 mm Hg (to reach 145 mm Hg on average) for the control group. Normal blood pressure (less than 130/80 mm Hg) was achieved in 64% of participants in the intervention group, while only 12% of those in the control group were successful. A recent update of the study showed that the beneficial effects of the intervention were long-lasting, with continued pressure reductions still observed one year after the start of the study.

These reductions in blood pressure obtained in the intervention group are of great importance, as several studies have clearly shown that pharmacological treatment of hypertension causes a significant reduction in the risk of cardiovascular diseases, including coronary heart disease and stroke, as well as kidney failure. This study therefore shows how important it is to know your blood pressure and, if it is above normal, to normalize it with medication or through lifestyle changes.

The importance of lifestyle
This last point is particularly important for the many people who have blood pressure slightly above normal, but without reaching values ​​as high as those of the participants of the study mentioned above (150/90 mm Hg and above). In these people, an increase in the level of physical activity, a reduction in sodium intake, and body weight loss can lower blood pressure enough to allow it to reach normal levels. For example, obesity is a major risk factor for hypertension and a weight loss of 10 kg is associated with a reduction in systolic pressure from 5 mm to 10 mm Hg. This positive influence of lifestyle is observed even in people who have certain genetic variants that predispose them to high blood pressure. For example, adopting an overall healthy lifestyle (normal weight, not smoking, regular physical activity, moderate alcohol consumption, and a good diet including sodium reduction) has been shown to be associated with blood pressure approximately 3 mm Hg lower and a 30% reduction in the risk of cardiovascular disease, regardless of the genetic risk. Conversely, an unhealthy lifestyle increases blood pressure and the risk of cardiovascular disease, even in those who are genetically less at risk of hypertension.

In short, taking your blood pressure regularly, even at a young age, can literally save your life. The easiest way to regularly check your blood pressure is to purchase one of the many models of blood pressure monitors available in pharmacies or specialty stores. Take the measurement in a seated position, legs uncrossed and with the arm resting on a table so that the middle of the arm is at the level of the heart. Two measurements in the morning before having breakfast and drinking coffee and two more measurements in the evening before bedtime (wait at least 2 hours after the end of the meal) generally give an accurate picture of blood pressure, which should be below 135/85 mm Hg on average according to Hypertension Canada.

Electronic cigarettes drastically reduce exposure to toxic substances from tobacco

Electronic cigarettes drastically reduce exposure to toxic substances from tobacco

OVERVIEW

  • Cigarette smoke contains more than 7,000 chemical compounds, of which at least 250 are well-characterized toxic substances and 70 are established carcinogens.
  • By allowing the absorption of nicotine without the combustion of tobacco, e-cigarettes are therefore an alternative to reduce exposure to these toxic compounds.
  • According to an analysis by the Institut Pasteur, this reduction is very significant since the aerosols generated by electronic cigarettes contain less than 1% of the toxic compounds found in cigarette smoke.

There is nothing worse than smoking for heart and blood vessel health (and health in general), and quitting smoking is by far the best decision a person can make to lower their risk of developing cardiovascular disease. However, quitting smoking is very difficult for many smokers, and, for several years, I have recommended that my patients who are unable to quit by conventional means (patches, gum, etc.) use electronic cigarettes.

In an e-cigarette, a solution of nicotine is heated to around 80°C using an atomizer, which generates an aerosol that allows vapers to inhale a small amount of nicotine (like smokers) to satisfy their addiction, but which does not contain the multiple toxic molecules that are generated during the combustion of tobacco (at around 900°C). This last point is the most important: contrary to what many think (including the majority of doctors), it is the combustion products of tobacco cigarettes that cause health problems, not nicotine. The latter is a drug that creates tobacco addiction and encourages people to smoke, but it has no major health effects and is especially not responsible for cardiovascular disease or lung cancer that result from smoking. The advantage of the electronic cigarette is therefore that it allows smokers who are highly dependent on nicotine to considerably reduce their exposure to the many toxic substances of cigarette smoke. This is a classic example of what is called harm reduction.

In addition, not only is the e-cigarette less toxic than tobacco, but a randomized clinical study recently published in the prestigious New England Journal of Medicine shows that it can be very useful for smoking cessation, with twice the effectiveness of traditional approaches based on nicotine substitutes. These devices therefore represent a very interesting technological innovation that adds a new dimension to the fight against tobacco.

Large-scale misinformation
That being said, one of the most disconcerting aspects of the media coverage surrounding anything related to e-cigarettes is the negative, often even alarmist, tone that is used to report the latest research developments on these devices. Any study that claims to show a negative impact of e-cigarettes on health makes headlines, even those that are low-quality and published in second-rate journals, while studies that instead report a positive effect are simply ignored, even when they are very scientifically sound and published in prestigious medical journals. This imbalance means that the population is informed only of the potential risks associated with e-cigarettes, without knowing that there is also a whole body of literature showing that these devices have positive effects on the health of smokers.

Perhaps one of the best examples of this media bias is the coverage of a study claiming to show an increased risk of heart attack in vapers, a study that was widely circulated in the media around the world when it was published. However, a critical examination of the results revealed that the majority of the 38 patients in the study had suffered a heart attack on average 10 years BEFORE they started vaping and therefore that these heart attacks could not have been due to e-cigarettes. Since vapers are almost always ex-smokers, the increase in heart attacks observed in vapers is simply due to the fact that these people gave up smoking after being sick and now use e-cigarettes to avoid a recurrence. This is a blatant case of scientific misconduct that resulted in the retraction of the article, but the withdrawal of this fraudulent study was not reported by most media. It should be noted that the main author of this retracted article, Stanton Glantz, is one of the most committed researchers against the use of e-cigarettes.

This is all the more unfortunate because a randomized clinical study, which was very well done, showed that it is exactly the opposite phenomenon that occurs, i.e. that the transition of smokers to e-cigarettes is positive because it is accompanied by a rapid improvement (in only one month) in the health of the blood vessels. However, this important study has not been reported by the media, and the public therefore does not know that, far from being harmful to the heart, e-cigarettes are instead associated with concrete health benefits for smokers.

The immediate consequence of this misinformation is that fewer and fewer people see e-cigarettes as a less harmful alternative to tobacco, including smokers, and there is a risk that the number of smokers who make the leap to e-cigarettes will decrease. I see it already in my practice: patients who weaned themselves off tobacco through vaping have resumed smoking, while others are reluctant to try e-cigarettes to quit smoking. In both cases, the reason given is the same: if vaping is as bad as smoking, why make the switch? This shows that disinformation campaigns can have real consequences for people’s lives and even literally make the difference between life and death for some of them.

Toxics reduction
Yet no one can seriously argue that e-cigarettes are as bad for your health as cigarettes. Cigarette smoke contains more than 7,000 chemical compounds, of which at least 250 are well-characterized toxic substances and 70 are established carcinogens. Repeated exposure to these toxic emissions is directly responsible for 8 million deaths each year worldwide, making smoking the leading cause of preventable deaths, especially those caused by cancer (30% of all cancers are caused by tobacco) and cardiovascular and respiratory diseases.

Analyses by Public Health England, the American National Academies of Sciences, Engineering, and Medicine and the British Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment all show that aerosols from e-cigarettes contain a much smaller number and amount of toxic substances than cigarette smoke and are therefore less harmful to health than smoked tobacco. It is for this reason that organizations such as Public Health England and France’s Académie nationale de médecine strongly recommend that smokers do not hesitate and make the transition to vaping.

This does not mean that e-cigarettes are completely safe, but they are undeniably much less harmful than the product they replace (which is the principle of harm reduction). By focusing only on identifying the potential harmful effects of vaping, we come to forget that the basic principle of vaping is to reduce the harms of smoking in smokers who are repeatedly exposed to toxic substances from tobacco.

A recent study by the Institut Pasteur provides a clear view of this potential for harm reduction. In this study, scientists compared the presence of two major classes of toxics (carbonyl compounds and aromatic hydrocarbons) in aerosols from smoked cigarettes, heated tobacco products (IQOS) and e-cigarettes. The results are really impressive: for the 19 carbonyls and 23 aromatic hydrocarbons tested, the e-cigarette chosen for the study (high-capacity tank device, used at maximum power) reduces these toxic compounds by 99.8 and 98.9% compared to tobacco cigarettes (Figure 1). IQOS (heated tobacco product) is also less toxic than cigarettes, with reductions of 85% and 96% in the concentration of these toxic compounds, but these reductions nevertheless remain lower than those observed with e-cigarettes, in line with previous studies.

Figure 1. Content of carbonyl compounds (A) and polycyclic aromatic hydrocarbons (PAHs) (B) in aerosols produced by a cigarette, a heated tobacco product and an e-cigarette. Note the drastic reduction of these two classes of toxics in e-cigarette vapour compared to tobacco smoke. From Dusautoir et al. (2020).

The researchers then compared the toxicity of different types of cigarettes by measuring the viability of bronchial epithelial cells following repeated exposure to aerosol puffs generated by cigarettes, heated tobacco products and e-cigarettes. As shown in Figure 2, exposing the cells to only 2 puffs from a cigarette is enough to kill half of the cells, and no residual cells are detectable after coming into contact with 10 puffs of smoke. Heated tobacco products significantly reduce this toxicity (40 puffs are necessary to kill half of the cells and a hundred to eliminate them completely), but it is here again that e-cigarettes are by far the least toxic, with all cells remaining alive even after exposure to 120 puffs of aerosols.

Figure 2. Viability of bronchial epithelial cells after repeated exposure to aerosols from a regular cigarette, a heated tobacco product or an e-cigarette. Note the high toxicity of cigarettes, which cause 50% mortality after cells are exposed to just 2 puffs of smoke, while cells remain viable even after being in contact with 120 puffs of aerosols from an e-cigarette. From Dusautoir et al. (2020).

Another study shows that this very significant reduction in toxicity is also observed for Juul, the e-cigarette which has recently captured the majority of the e-cigarette market (see our article on this subject). Compared to traditional cigarettes, the vapour generated by Juul contains almost 100% less carbon monoxide and carbonyl compounds like acetaldehyde, formaldehyde, and acrolein (a major irritant in cigarette smoke) (Table 1). Similar results were also reported in another study. These data are important because Juul is particularly popular among young vapers. Contrary to what we often hear, the vast majority of young people (> 99%) who regularly vape are occasional or regular smokers and these people can therefore substantially reduce their exposure to tobacco toxins by vaping. In addition, recent data indicates that nicotine absorbed through e-cigarettes is less addictive than when it comes from burning tobacco, which decreases the risk of developing longer-term dependence.

Table 1. Concentration of certain toxic compounds present in cigarette smoke or in the vapour generated by the Juul e-cigarette. From Son et al. (2020).

It is worth remembering that the ultimate goal of tobacco control is to reduce the incidence of smoking-related diseases, especially cardiovascular disease and lung cancer. To achieve this, total abstinence is desirable, but the large number of people who are unable to quit smoking on their own or by using current cessation tools and therefore remain at risk of dying prematurely must be taken into account. In my clinical experience over the past ten years, the electronic cigarette is the most popular nicotine replacement for smokers and for many of them represents the only approach that allows them to successfully quit smoking. Instead of constantly seeking to discredit these devices, as is currently the case, they should instead be seen as a technological innovation that can greatly contribute to the fight against diseases caused by smoking, and we need to clearly inform smokers of the benefits associated with the transition to vaping.