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The goal of this study was to evaluate the differences in urine cotinine (UC) concentration based on the use of conventional cigarettes, e-cigarettes (ECs), and dual product use, and determine the use of ECs in the real world.    METHODS  In total, 15099 subjects were classified into non-smokers, cigarette smokers (c-smokers), e-cigarette smokers (e-smokers), and dual users, and their UC (a classical biomarker of smoking) values were compared. Analysis of covariance (ANCOVA) was performed after adjusting for age, sex and job status to analyze the differences in UC concentration in relation to type of smoking. The reasons for using ECs and the experience of cigarette use before using ECs were analyzed.    RESULTS  Of the 15099 people, 76.4% were non-smokers, 20.9% c-smokers, 2.3% dual users, and 0.4% were e-smokers. There were significant differences in UC concentration among the groups (p<0.001). The geometric mean (GM) UC concentration was 4.45 ng/mL. UC concentration was the highest among dual users (GM: 1030.5, median: 1258.9 ng/mL), followed by c-smokers (GM: 842.5, median: 1163.0 ng/mL), e-smokers (GM: 119.5, median: 309.7 ng/mL), and non-smokers (GM: 0.8, median: 0.8 ng/mL). Among the EC users, the rate of using ECs for health or social convenience was 81.9%. Among e-smokers, 11.4% had never smoked previously.    CONCLUSIONS  The UC concentration was the highest among dual users. However, for the female population, the UC concentration was the highest among e-smokers. The vast majority of EC users were dual users. In addition, there were no differences in the frequency of cigarette smoking between the dual user and c-smoker groups. Consequently, EC use did not lead to a decrease in cigarette use, but did lead to an increase in UC concentration. Therefore, in the real world, dual users have higher cotinine levels than the other groups, which could indicate that they take more nicotine by cigarettes or ECs, or are more addicted than others.

Differences between the effects of conventional cigarettes, e-cigarettes and dual product use on urine cotinine levels