E-cigs vs. T-cigs
Electronic cigarettes may be less harmful in the UK than cigarettes but may still be dangerous. Under which circumstances should a person use ecigs? Will they fill your body with plastic?
Electronic cigarettes can contain propylene glycol or vegetable glycerine with nicotine (and in at least two cases polyethylene glycol 400) to form a solution that when heated by an atomizer, produces a visible vapour that provides nicotine to the bloodstream via the lungs when inhaled.
Electronic cigarettes have not been studied enough by scientists in laboratories to form conclusive evidence that their use is either beneficial or harmful to humans. However, some are concerned that unknown side-effects could occur with continuous, consistent use of electronic cigarettes, including cancer.
Behaviour surrounding their use is worrisome because e-cigs are being used habitually by a percentage of non-smokers who otherwise would not use nicotine, they may seem attractive to children, they are not closely regulated, and their use makes it very easy to overdose on nicotine even for experienced smokers.
UK Electronic Cigarettes and E-LiquidVarious types of e-cigarettes.
Electronic cigarettes or e-cigarettes[note 1] are handheld electronic devices that try to create a feeling like smoking tobacco. They work by heating a liquid to generate an aerosol, commonly called a "vapor", that the user inhales. Using e-cigarettes is sometimes called vaping. The liquid in the e-cigarette, called e-liquid, is usually made of nicotine, propylene glycol, glycerine, and flavorings. Not all e-liquids contain nicotine.
The health risks of e-cigarettes are uncertain. They are likely safer than tobacco cigarettes, but the long-term health effects are not known. They can help some smokers quit. When used by non-smokers, e-cigarettes can lead to nicotine addiction, and there is concern that children could start smoking after using e-cigarettes. According to some US sources, minors who use e-cigarettes are more likely to smoke later in life. Public Health England attributes this link to a liability for the use of both products rather than one resulting in the other. So far, no serious adverse effects have been reported in trials. Less serious adverse effects include throat and mouth irritation, vomiting, nausea, and coughing.
E-cigarettes create an aerosol, commonly called vapor, generally containing nicotine, flavors, glycerol and propylene glycol. Its exact composition varies. The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette aerosol. Those present are mostly below 1% corresponding levels in tobacco smoke. The aerosol can contain toxicants and traces of heavy metals at levels permissible in inhalation medicines, and potentially harmful chemicals not found in tobacco smoke at concentrations permissible by workplace safety standards. However, chemical concentrations may exceed the stricter public safety limits.
The modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, and as of 2015 most e-cigarettes are made in China. Since they were first sold in 2004 their global use has risen exponentially. In the United States and the United Kingdom their use is widespread, and some US schoolchildren use them. Reasons for using e-cigarettes involve trying to quit smoking, reduce risk, or save money, though many use them recreationally. A majority of users still smoke tobacco, causing concerns that dual use may "delay or deter quitting". About 60% of UK users are smokers and roughly 40% are ex-smokers, while use among never-smokers is "negligible". Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is debated in many countries. A European directive in 2016, set limits for liquids and vaporizers, ingredients, and child-proof liquid containers. As of August 2016, the US FDA extended its regulatory power to include e-cigarettes. There are around 500 brands of e-cigarette with global sales in excess of US$7 billion.
Electronic cigarettes are also known as e-cigarettes, e-cigs, EC, electronic nicotine delivery systems (ENDS) or electronic non-nicotine delivery systems (ENNDS), personal vaporizers, or PVs. They are handheld devices, often made to look like conventional cigarettes, and used in a similar way. E-liquid or juice are names for the flavored solution that goes inside the e-cigarette. An aerosol, or vapor, is produced by heating the e-liquid. Irish public health discussions refer to NMNDS ("non-medicinal nicotine delivery systems").Aerosol (vapor) exhaled by an e-cigarette user.
Since their introduction to the market in 2004, global usage of e-cigarettes has risen exponentially. By 2013, there were several million users globally. Awareness and use of e-cigarettes greatly increased in a relatively short period of time. However, growth in the US and UK had reportedly slowed in 2015, lowering market forecasts for 2016.
Most users have a history of smoking regular cigarettes. At least 52% of smokers or ex-smokers have vaped. Of smokers who have, less than 15% became everyday e-cigarette users. Though e-cigarette use among those who have never smoked is very low, it continues to rise. A survey of e-cigarette users conducted from 2011–2012 found that only 1% of respondents used liquid without nicotine.
Everyday use is common among e-cigarette users. Vapers mostly keep smoking, although many say vaping helps them cut down or quit smoking. Most e-cigarette users are middle-aged men who also smoke traditional cigarettes, either to help them quit or for recreational use. E-cigarette use was also rising among women as of 2014. Some young people who have tried an e-cigarette have never smoked tobacco, so ECs can be a starting point for nicotine use. On the other hand, Public Health England found no evidence e-cigarettes increase teen tobacco smoking. They noted tentative evidence that e-cigarettes divert youth away from cigarettes. A 2014 review raised ethical concerns about minors' e-cigarette use and the potential to weaken cigarette smoking reduction efforts.
In the US, as of 2014, 12.6% of adults had used an e-cigarette at least once and approximately 3.7% were still using them. 1.1% of adults were daily users. Non-smokers and former smokers who had quit more than four years earlier were extremely unlikely to be current users. Former smokers who had recently quit were more than four times as likely to be daily users as current smokers. Experimentation was more common among younger adults, but daily users were more likely to be older adults.Play media National Institute on Drug Abuse director Nora Volkow discussing a study that shows teens using e-cigarettes are more likely to start smoking tobacco.
The recent decline in smoking has accompanied a rapid growth in the use of alternative nicotine products among young people and young adults. In the US, vaping among young people exceeded smoking in 2014. As of 2014, up to 13% of American high school students have used them. Between 2013 and 2014, vaping among students tripled. In 2013 the Centers for Disease Control and Prevention (CDC) estimated that around 160,000 students between 2011 and 2012 who had tried vaping had never smoked. E-cigarette use among never-smoking youth in the US correlates with elevated desires to use traditional cigarettes. Teenagers who had used an e-cigarette were more inclined to become smokers than those who had not. In the 2015 Monitoring the Future survey, a majority of students who used electronic cigarettes reported using liquid without nicotine the last time they vaped. The majority of young people who vape also smoke. A 2010–2011 survey of students at two US high schools found that vapers were more likely to use hookah and blunts than smokers. Among grade 6 to 12 students in the US, the proportion who have tried them rose from 3.3% in 2011 to 6.8% in 2012. Those still vaping over the last month rose from 1.1% to 2.1% and dual use rose from 0.8% to 1.6%. Over the same period, the proportion of grade-6-to-12 students who regularly smoke tobacco fell from 7.5% to 6.7%.
In the UK, user numbers have increased from 700,000 in 2012 to 2.6 million in 2015, but use by current smokers remained flat at 17.6% from 2014 into 2015 (in 2010, it was 2.7%). About one in 20 adults in the UK uses e-cigarettes. In the UK in 2015, 18% of regular smokers said they used e-cigarettes and 59% said they had used them in the past. Among those who had never smoked, 1.1% said they had tried them and 0.2% still use them. In 2013, among those under 18, 7% have used e-cigarettes at least once. Among non-smokers' children, 1% reported having tried e-cigarettes "once or twice", and there was no evidence of continued use. About 60% of all users are smokers and most of the rest are ex-smokers, with "negligible" numbers of never-smokers. In 2015 figures showed around 2% monthly EC-usage among under-18s, and 0.5% weekly, and despite experimentation, "nearly all those using EC regularly were cigarette smokers". 10–11-year-old Welsh never-smokers are more likely to use e-cigarettes if a parent used e-cigarettes.
In France in 2014, between 7.7 and 9.2 million people have tried e-cigarettes and 1.1 to 1.9 million use them on a daily basis. 67% of French smokers use e-cigarettes to reduce or quit smoking. Of French people who have tried e-cigarettes, 9% have never smoked tobacco. Of the 1.2% who had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited e-cigarettes as essential in quitting.
The frequency of vaping in youth is low. Minors who use one tobacco product such as e-cigarettes are more likely to later use other tobacco products such as cigarettes, which likely arises from a common liability for the use of both products. Young people who vape but do not smoke are more likely to try smoking than their peers who do not vape.E-cigarettes often have a high-tech look. Candy, fruit and coffee flavored e-liquid.
Reasons for e-cigarette use often relate to quitting smoking and recreation. Many users believe vaping is healthier than smoking, although some are concerned about possible adverse health effects. Some use them to circumvent smoke-free laws and policies, or to cut back on cigarette smoking. 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking. In the same survey, 26% of respondents would use them in areas where smoking was banned. Not having odor from smoke on clothes on some occasions prompted interest in or use of e-cigarettes. Many e-cigarette users use them because they believe they are safer than conventional cigarettes.
Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one. College students often vape for experimentation. Expensive marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use". Exposure to e-cigarette advertising influenced people to try them.
Some researchers are concerned about vaping during pregnancy. E-cigarettes feel or taste similar to traditional cigarettes, and vapers disagreed about whether this was a benefit or a drawback. The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.
Some users stopped vaping due to issues with the devices. Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use. Some surveys found that a small percentage of users' motives were to avoid smoking bans, but other surveys found that over 40% of users said they used the device for this reason.
The health and lifestyle appeal may also encourage young non-smokers to use e-cigarettes, as they may perceive that trying e-cigarettes is less risky and more socially appealing. This may decrease negative beliefs or concerns about nicotine addiction. Marketing might appeal to young people as well as adults. Adolescent experimenting with e-cigarettes may be sensation seeking behavior, and is not likely to be associated with tobacco reduction or quitting smoking. Young people may view e-cigarettes as a symbol of rebellion. The main reasons young people experimented with e-cigarettes were due to curiosity, flavors, and peer influences. The National Association of County and City Health Officials say there is concern that e-cigarettes may appeal to youth because of their high-tech design, assortment of flavors, and accessibility online. The Heart and Stroke Foundation claims that candy and fruit flavored e-cigarettes are designed to appeal to young people. Infants and toddlers could ingest the e-liquid from an e-cigarette device out of curiosity.
Users may begin by trying a disposable e-cigarette. Users often start with e-cigarettes resembling normal cigarettes, eventually moving to a later-generation device. Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit", and users may adjust their devices to provide more vapor for better "throat hits".Special e-liquid mixes with THC or other cannabinoids are sold.
The emergence of e-cigs has given cannabis smokers a new method of inhaling cannabinoids. E-cigs differ from traditional marijuana cigarettes in several respects. It is assumed that vaporizing cannabinoids at lower temperatures is safer because it produces smaller amounts of toxic substances than the hot combustion of a marijuana cigarette. Recreational cannabis users can discreetly "vape" deodorized cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as "stealth vaping". While cannabis is not readily soluble in the liquid used for e-cigs, recipes containing synthetic cannabinoids which are soluble may be found on the Internet.
E-cigarettes may be used with other substances and cartridges can potentially be filled with e-liquid containing substances other than nicotine, thus serving as a new and potentially dangerous way to deliver other psychoactive drugs, for example THC.
Cannabinoid-enriched e-liquids require lengthy, complex processing. Some are available on the Internet despite lack of quality control, expiry date, conditions of preservation, or any toxicological and clinical assessment. The health consequences of vaping cannabis preparations are largely unknown.Exploded view of electronic cigarette with transparent clearomizer and changeable dual-coil head. This model allows for a wide range of settings. Electronic cigarettes can come in very different forms—such as this hand-grenade-shaped variant.
The main components of an e-cigarette are a mouthpiece, a cartridge (tank), a heating element/atomizer, a microprocessor, a battery, and possibly a LED light on the end. The only exception to this are mechanical e-cigarettes (mods) which contain no electronics; the circuit is closed by a mechanical action switch. An atomizer comprises a small heating element, or coil, that vaporizes e-liquid and wicking material that draws liquid onto the coil. When the user pushes a button, or (in some variations) activates a pressure sensor by inhaling, the heating element atomizes the liquid solution. The e-liquid reaches a temperature of roughly 100-250 °C within a chamber to create an aerosolized vapor, which the user then inhales, rather than cigarette smoke. The aerosol provides a flavor and feel similar to tobacco smoking.
There are three main types of e-cigarettes: cigalikes, looking like cigarettes; eGos, bigger than cigalikes with refillable liquid tanks; and mods, assembled from basic parts or by altering existing products. As the e-cigarette industry continues to evolve, new products are quickly developed and brought to market. First generation e-cigarettes tend to look like tobacco cigarettes and so are called "cigalikes". Most cigalikes look like cigarettes but there is some variation in size. A traditional cigarette is smooth and light while a cigalike is rigid and slightly heavier. Second generation devices are larger overall and look less like tobacco cigarettes. Third generation devices include mechanical mods and variable voltage devices. The fourth generation includes Sub ohm tanks and temperature control devices. The power source is the biggest component of an e-cigarette, which is frequently a rechargeable lithium-ion battery.
E-liquid is the mixture used in vapor products such as e-cigarettes and generally consists of propylene glycol, glycerin, water, nicotine, and flavorings. While the ingredients vary the liquid typically contains 95% propylene glycol and glycerin. There are many e-liquids manufacturers in the USA and worldwide, and upwards of 8,000 flavors. While there are currently no US Food and Drug Administration (FDA) manufacturing standards for e-liquid, the FDA has proposed regulations that were expected to be finalized in late 2015.[needs update] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).Main article: Positions of medical organizations on electronic cigarettes 2014 Centers for Disease Control (CDC) press release about e-cigarettes.
Medical organizations differ about the health implications of vaping. Many medical organizations have made statements about their health and safety. There is general agreement that e-cigarettes expose users to fewer toxicants than tobacco. International organizations have hesitated to recommend e-cigarettes for quitting smoking, because of limited evidence of effectiveness and safety. Some from the UK have recommended their use by smokers unwilling or unable to quit.
In August 2016, a World Health Organization (WHO) report found "there is not enough research to quantify the relative risk of ENDS/ENNDS over combustible products. Therefore, no specific figure about how much 'safer' the use of these products is compared to smoking can be given any scientific credibility at this time." In July 2014, a WHO report found limited evidence that e-cigarettes may help some smokers quit, but did not reach conclusions. Smokers should be encouraged to use approved methods for help with quitting, although e-cigarettes may have a role in helping those who have failed to quit by other means. Smokers will get the maximum health benefit if they completely quit all nicotine use. A policy briefing by the Framework Convention Alliance notes widespread agreement that e-cigarettes are "almost certainly considerably less hazardous for individuals than cigarettes", but also notes widespread disagreement on the likelihood and impact of dual use, uptake by never-smokers, and re-normalisation of smoking. The World Lung Foundation has applauded the WHO report's recommendation of tighter regulation due to safety concerns and the risk of increased nicotine addiction or tobacco use among young people.
In a 2015 joint statement, Public Health England and twelve other UK medical bodies concluded "e-cigarettes are significantly less harmful than smoking". PHE also stated that e-cigarettes are estimated to be 95% less harmful than smoking. The UK National Health Service believes that e-cigarettes have about 5% of the risk of tobacco cigarettes, but also feels there will not be a complete understanding of their safety for many years. There are clinical trials in progress to test the quality, safety and effectiveness of e-cigarettes, but until these are complete the NHS maintains that the government could not give any advice on them or to recommend their use. In 2016, the Royal College of Physicians called to "promote e-cigarettes widely as substitute for smoking", concluding that "e-cigarettes are likely to be beneficial to UK public health".The United States Centers for Disease Control and Prevention released a 2016 report titled E-cigarette Ads and Youth which concerned marketing towards adolescents.
In 2016, the FDA stated its position that e-cigarettes are "likely less hazardous for an individual user than continued smoking of traditional cigarettes", but that the net population effect is unknown. In 2015, the United States Preventive Services Task Force concluded there is insufficient evidence to recommend e-cigarettes for smoking cessation, and recommended clinicians instead recommend more proven smoking cessation aids. The National Institute on Drug Abuse raises concern over the possibility that they could perpetuate nicotine addiction and thus interfere with quitting. In 2015, the American Academy of Pediatrics strongly recommended against using e-cigarettes to quit smoking, stating that for adolescents e-cigarettes are not effective in treating tobacco dependence. In August 2014, the American Heart Association released a policy statement concluding that while e-cigarette aerosol is much less toxic then cigarette smoke, there is insufficient evidence for clinicians to counsel smokers to use them as a primary cessation aid. If a patient failed initial treatment or refuses to use cessation medication, and wishes to use e-cigarettes to quit, it is reasonable to support the attempt after informing about the uncertainties. In 2014, the US FDA said "E-cigarettes have not been fully studied, so consumers currently don't know: the potential risks of e-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products. Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death."Play media CDC launches "Tips From Former Smokers" ad campaign in 2015. The main information on e-cigarettes begins at 24:45.
The available research on e-cigarette use for smoking cessation is limited to three randomized controlled trials and some user surveys, case reports, and cohort studies. Some consider the evidence contradictory, while others attribute negative outcomes to inappropriate study design. Some medical authorities recommend that e-cigarettes have a role in smoking cessation, and others disagree. On the one hand, Public Health England recommends that stop-smoking practitioners should (1) advise people who want to quit to try e-cigarettes if they are failing with conventional nicotine replacement therapy (NRT); and (2) advise people who cannot or do not want to quit to switch to e-cigarettes. On the other hand, the United States Preventive Services Task Force advised only use of conventional NRT products in smoking cessation and found insufficient evidence to recommend e-cigarettes for this purpose.
There is tentative evidence that they can help people quit smoking, but studies pertaining to their potential impact on smoking cessation and reduction is very limited. However, a 2016 meta-analysis based on 20 different studies found that smokers who used electronic cigarettes were 28% less likely to quit than those who had not tried electronic cigarettes. This finding persisted whether the smokers were initially interested in quitting or not. A 2015 meta-analysis on clinical trials found that nicotine-containing e-liquids are more effective than nicotine-free ones for quitting smoking. They compared their finding that nicotine-containing e-cigarettes helped 20% of people quit with the results from other studies that found conventional NRT helps 10% of people quit. There has only been one study directly comparing first generation e-cigarettes to conventional NRT as smoking cessation tools, so the comparative effectiveness is not known. Two 2016 reviews found a trend towards benefit of e-cigarettes with nicotine for smoking cessation, but that the evidence was of low quality. Another 2016 review found that the combined abstinence rate among smokers using e-cigarettes in prospective studies was 29.1%. The same review noted that few clinical trials had yet been conducted on their effectiveness, and only one had included a group using other cessation methods.
However, e-cigarettes have not been subject to the same efficacy testing as nicotine replacement products. Several authorities, including the World Health Organisation, take the view that there is not enough evidence to recommend e-cigarettes for quitting smoking in adults, and there are studies showing a decline in smoking cessation among dual users. A 2014 review found that e-cigarettes do not seem to improve cessation rates compared to regulated nicotine replacement products, and a trial found 29% of e-cigarette users were still vaping at 6 months, but only 8% of patch users still wore patches at 6 months. There is low-quality evidence that vaping assists smokers to quit smoking in the long-term compared with nicotine-free vaping. Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine. E-cigarettes without nicotine may reduce tobacco cravings because of the smoking-related physical stimuli.
Tobacco harm reduction (THR) is replacing tobacco cigarettes with lower risk products to reduce death and disease. THR has been controversial out of fear that tobacco companies cannot be trusted to make products that will reduce this risk. E-cigarettes can reduce smokers' exposure to carcinogens and other toxic substances found in tobacco.
Tobacco smoke contains 100 known carcinogens, and 900 potentially cancer causing chemicals, none of which has been found in more than trace quantities in e-cigarette vapor. While e-cigarettes cannot be considered "safe" because there is no safe level for carcinogens, they are doubtless safer than tobacco cigarettes. E-cigarettes are not dangerous enough to warrant serious public health concerns given the known risks of conventional cigarettes. The same review concluded that evidence supported "the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking", provided efforts were also made to protect vulnerable groups from e-cigarettes.
A core concern is that smokers who could have quit completely will develop an alternative nicotine addiction instead. A 2014 review stated that promotion of vaping as a harm reduction aid is premature, but they could help to lower tobacco-related death and disease if examined more thoroughly. Another review found that compared with cigarettes, e-cigarettes are likely to be much less, if at all, harmful to users or bystanders. The authors warned against the potential harm of excessive regulation and advised health professionals to consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking. A 2015 Public Health England report concluded that e-cigarette use "releases negligible levels of nicotine into ambient air with no identified health risks to bystanders". A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction. A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions. E-cigarette use for risk reduction in high-risk groups such as people with mental disorders is unavailable.
Hazards associated with products currently on the market are probably low, and certainly much lower than smoking. However, harms could be reduced further through appropriate product standards. Many smokers want to reduce harm from smoking by using these products. The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking. The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and smokeless tobacco for long term use instead of smoking. In an interview, the director of the Office on Smoking and Health for the U.S. federal agency Centers for Disease Control and Prevention (CDC) believes that there is enough evidence to say that using e-cigarettes is likely less harmful than smoking a pack of conventional cigarettes. However, due to the lack of regulation of the contents of e-cigarettes and the presence of nicotine, the CDC has issued warnings. A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both. This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."Main articles: Safety of electronic cigarettes and Electronic cigarette aerosol and e-liquid Adverse effects of vaping.
The safety of electronic cigarettes is uncertain. However, they are likely substantially safer than tobacco cigarettes. There is considerable variation between vaporizers and in quality of their liquid ingredients and thus the contents of the vapor. Reviews on the safety of electronic cigarettes, analyzing almost the same studies, resulted in substantially different conclusions. In July 2014 the World Health Organization (WHO) report cautioned about potential risks of using e-cigarettes. Regulated US Food and Drug Administration (FDA) products such as nicotine inhalers are probably safer than e-cigarettes. In 2015, Public Health England stated that e-cigarettes are estimated to be 95% less harmful than smoking. A 2014 systematic review concluded that the risks of e-cigarettes have been exaggerated by health authorities and stated that while there may be some remaining risk, the risk of e-cigarette use is likely small compared to smoking tobacco.
The long-term effects of e-cigarette use are unknown. Improvements in lung function and pulmonary health have been demonstrated among smokers who have switched to e-cigarettes. A 2014 Cochrane review found no serious adverse effects reported in clinical trials. Less serious adverse effects from e-cigarette use include throat and mouth irritation, vomiting, nausea, and cough. The evidence suggests they produce less harmful effects than tobacco. A 2014 WHO report said, "ENDS use poses serious threats to adolescents and fetuses." Aside from toxicity, there are also risks from misuse or accidents such as contact with liquid nicotine, fires caused by vaporizer malfunction, and explosions as result from extended charging, unsuitable chargers, or design flaws. Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns. There is a small risk of battery explosion in devices modified to increase battery power.
The e-liquid has a low level of toxicity, but contamination with various chemicals has been found. The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor. Those which are present are mostly below 1% of the corresponding levels in tobacco smoke, and far below safety limits for occupational exposure. Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals. Normal usage of e-cigarettes generates very low levels of formaldehyde. A 2015 review found that later-generation e-cigarettes set at higher power may generate equal or higher levels of formaldehyde compared to smoking. A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage. The 2015 Public Health England report looking at the research concluded that by applying maximum power and increasing the time the device is used on a puffing machine, e-liquids can thermally degrade and produce high levels of formaldehyde. Users detect the "dry puff" and avoid it, and the report concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes." E-cigarette users who use e-cigarettes that contain nicotine are exposed to its potentially harmful effects. Nicotine is associated with cardiovascular disease, potential birth defects, and poisoning.In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo. There is inadequate research to demonstrate that nicotine is associated with cancer in humans. The risk is probably low from the inhalation of propylene glycol and glycerin. No information is available on the long-term effects of the inhalation of flavors. Most of the cardiovascular effects of ECs are consistent with those of nicotine. According to a 2017 review, it is possible that ECs may have adverse cardiovascular effects on users, especially those who already have cardiovascular disease. However, this review also concluded that "the risk is thought to be less than that of cigarette smoking based on qualitative and quantitative comparisons of EC aerosol versus cigarette smoke constituents."
E-cigarettes create vapor that consists of ultrafine particles, with the majority of particles in the ultrafine range. The vapor has been found to contain flavors, propylene glycol, glycerin, nicotine, tiny amounts of toxicants, carcinogens, heavy metals, and metal nanoparticles, and other chemicals. Exactly what comprises the vapor varies in composition and concentration across and within manufacturers. However, e-cigarettes cannot be regarded as simply harmless. There is a concern that some of the mainstream vapor exhaled by e-cigarette users can be inhaled by bystanders, particularly indoors. E-cigarette use by a parent might lead to inadvertent health risks to offspring. A 2014 review recommended that e-cigarettes should be regulated for consumer safety. There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges. A 2014 review found "disposable e-cigarettes might cause an electrical waste problem."
The World Health Organization has concluded regarding second hand aerosol (SHA) "that while there are a limited number of studies in this area, it can be concluded that SHA is a new air contamination source for particulate matter, which includes fine and ultrafine particles, as well as 1,2-propanediol, some VOCs [volatile organic compounds], some heavy metals, and nicotine" and "[i]t is nevertheless reasonable to assume that the increased concentration of toxicants from SHA over background levels poses an increased risk for the health of all bystanders". Public Health England has concluded that "international peer-reviewed evidence indicates that the risk to the health of bystanders from secondhand e-cigarette vapour is extremely low and insufficient to justify prohibiting e-cigarettes". A systematic review concluded, "the absolute impact from passive exposure to EC [electronic cigarette] vapour has the potential to lead to adverse health effects. The risk from being passively exposed to EC vapour is likely to be less than the risk from passive exposure to conventional cigarette smoke."
Nicotine, a key ingredient in e-liquids, is a highly addictive substance, on a level comparable to heroin and cocaine. Nicotine stimulates regions of the cortex associated with reward, pleasure and reducing anxiety. When nicotine intake stops, withdrawal symptoms include cravings for nicotine, anger/irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger or weight gain, and difficulty concentrating. It is not clear whether e-cigarette use will decrease or increase overall nicotine addiction, but the nicotine content in e-cigarettes is adequate to sustain nicotine dependence.
The World Health Organization is concerned about addiction for non-smokers, and the National Institute on Drug Abuse said e-cigarettes could maintain nicotine addiction in those who are attempting to quit. The limited available data suggests that the likelihood of abuse from e-cigarettes is smaller than traditional cigarettes. A 2014 systematic review found that the concerns that e-cigarettes could lead non-smokers to start smoking are unsubstantiated. No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction, but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.
Many studies have focused on young people, since youthful experimentation with e-cigarettes could lead to lifelong addiction. Various organizations, including the UATLD, the AAP and the FDA, have expressed concern that e-cigarette use could increase nicotine addiction in youth. Although regular use of e-cigarettes is generally very low by people who have never smoked, significant numbers of teenagers who have never smoked tobacco have experimented with e-cigarettes. The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown, as is the extent to which e-cigarette use could lead to addiction or substance dependence in youth.
Smoking a traditional cigarette yields between 0.5 and 1.5 mg of nicotine, but the nicotine content of the cigarette is only weakly correlated with the levels of nicotine in the smoker's bloodstream. The amount of nicotine in the e-cigarette aerosol varies widely either from puff-to-puff or among products of the same company. In practice e-cigarette users tend to reach lower blood nicotine concentrations than smokers, particularly when the users are inexperienced or using earlier-generation devices. Nicotine in tobacco smoke is absorbed into the bloodstream rapidly, and e-cigarette vapor is relatively slow in this regard. The concentration of nicotine in e-liquid ranges up to 36 mg/mL. New EU regulations cap this at a maximum of 2% (20 mg/mL), but this is an arbitrary ceiling based on limited data. In practice the nicotine concentration in an e-liquid is not a reliable guide to the amount of nicotine that reaches the bloodstream.
The earliest e-cigarette can be traced to American Herbert A. Gilbert, who in 1963 patented "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device produced flavored steam without nicotine. The patent was granted in 1965. Gilbert's invention was ahead of its time. There were prototypes, but it received little attention and was never commercialized because smoking was still fashionable at that time. Gilbert said in 2013 that today's electric cigarettes follow the basic design set forth in his original patent.
Hon Lik, a Chinese pharmacist and inventor who worked as a research pharmacist for a company producing ginseng products, is credited with the invention of the modern e-cigarette. Lik quit smoking after his father, also a heavy smoker, died of lung cancer. In 2001, he thought of using a high frequency, piezoelectric ultrasound-emitting element to vaporize a pressurized jet of liquid containing nicotine. This design creates a smoke-like vapor. Lik said that using resistance heating obtained better results and the difficulty was to scale down the device to a small enough size. Lik's invention was intended to be an alternative to smoking.The Ruyan e-cigar was first launched in China in 2004.
Hon Lik registered a patent for the modern e-cigarette design in 2003. The e-cigarette was first introduced to the Chinese domestic market in 2004. Many versions made their way to the U.S., sold mostly over the Internet by small marketing firms. E-cigarettes entered the European market and the US market in 2006 and 2007. The company that Lik worked for, Golden Dragon Holdings, registered an international patent in November 2007. The company changed its name to Ruyan (如烟, literally "Resembling smoking") later the same month and started exporting its products. Many US and Chinese e-cig makers copied his designs illegally, so Lik has not received much financial reward for his invention (although some US manufacturers have compensated him through out of court settlements). Ruyan later changed its company name to Dragonite International Limited. Most e-cigarettes today use a battery-powered heating element rather than the earlier ultrasonic technology design.
When e-cigarettes entered the international market, some users were dissatisfied with their performance, and the e-cigarette continued to evolve from the first generation three-part device. In 2007 British entrepreneurs Umer and Tariq Sheikh invented the cartomizer. This is a mechanism that integrates the heating coil into the liquid chamber. They launched this new device in the UK in 2008 under their Gamucci brand, and the design is now widely adopted by most "cigalike" brands. Other users tinkered with various parts to produce more satisfactory homemade devices, and the hobby of "modding" was born. The first mod to replace the e-cigarette's case to accommodate a longer-lasting battery, dubbed the "screwdriver", was developed by Ted and Matt Rogers in 2008. Other enthusiasts built their own mods to improve functionality or aesthetics. When pictures of mods appeared at online vaping forums many people wanted them, so some mod makers produced more for sale.
The demand for customizable e-cigarettes prompted some manufacturers to produce devices with interchangeable components that could be selected by the user. In 2009, Joyetech developed the eGo series which offered the power of the screwdriver model and a user-activated switch to a wide market. The clearomizer was invented in 2009. Originating from the cartomizer design, it contained the wicking material, an e-liquid chamber, and an atomizer coil within a single clear component. The clearomizer allows the user to monitor the liquid level in the device. Soon after the clearomizer reached the market, replaceable atomizer coils and variable voltage batteries were introduced. Clearomizers and eGo batteries became the best-selling customizable e-cigarette components in early 2012.
International tobacco companies dismissed e-cigarettes as a fad at first. However, recognizing the development of a potential new market sector that could render traditional tobacco products obsolete, they began to produce and market their own brands of e-cigarettes and acquire existing e-cigarette companies.blu eCigs, a prominent US e-cigarette manufacturer, was acquired by Lorillard Inc. in 2012.British American Tobacco was the first tobacco business to sell e-cigarettes in the UK. They launched Vype in 2013, while Imperial Tobacco's Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite International Limited for $US 75 million in 2013 and launched Puritane in partnership with Boots UK. On 1 October 2013 Lorillard Inc. acquired another e-cigarette company, this time the UK based company SKYCIG. SKY was rebranded as blu. On 3 February 2014, Altria Group, Inc. acquired popular electronic cigarette brand Green Smoke for $110 million. The deal was finalized in April 2014 for $110 million with $20 million in incentive payments. Altria also markets its own e-cigarette, the MarkTen, while Reynolds American has entered the sector with its Vuse product. Philip Morris, the world's largest tobacco firm, purchased UK's Nicocigs in June 2014. On 30 April 2015, Japan Tobacco bought the US Logic e-cigarette brand. Japan Tobacco also bought the UK E-Lites brand in June 2014. On 15 July 2014, Lorillard sold blu to Imperial Tobacco as part of a deal for $7.1 billion.
In 2014, dollar sales of customizable e-cigarettes and e-liquid surpassed sales of cigalikes in the US, despite the fact that customizables are less expensive.
Consumers of e-cigarettes, sometimes called "vapers", have shown passionate support for e-cigarettes that other nicotine replacement therapies did not receive. This suggests e-cigarettes have potential mass appeal that could challenge combustible tobacco's market position.
A subculture of "vapers" has emerged. Members of this emerging subculture often see e-cigarettes as a safer alternative to smoking, and some view it as a hobby. The online forum Electronic Cigarette Forum was one of the first major communities. It and other online forums, such as UKVaper.org, were the origins of the hobby of modding. There are also groups on Facebook and Reddit. Online forums based around modding have grown in the vaping community. Vapers energetically embrace activities associated with e-cigarettes and sometimes act as unpaid evangelists according to a 2014 review. A 2014 Postgraduate Medical Journal editorial stated that e-cigarette companies have a substantial online presence, as well as many individual vapers who blog and tweet about e-cigarette related products. The editorial stated that vapers "also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks". A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda. The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws. The same review said this is similar to tobacco industry activity going back to the 1980s. These approaches were used in Europe to minimize the EU Tobacco Product Directive in October 2013. True grassroots lobbying also influenced the TPD decision.Rebecca Taylor, a member of the European Parliament, stated, "to say it's an orchestrated campaign is absolute rubbish." Contempt for "big tobacco" is part of vaping culture.E-cigarette user blowing a cloud of aerosol (vapor). The activity is known as cloud-chasing.
Large gatherings of vapers, called vape meets, take place around the US. They focus on e-cig devices, accessories, and the lifestyle that accompanies them. Vapefest, which started in 2010, is an annual show hosted by different cities. People attending these meetings are usually enthusiasts that use specialized, community-made products not found in convenience stores or gas stations. These products are mostly available online or in dedicated "vape" storefronts where mainstream e-cigarettes brands from the tobacco industry and larger e-cig manufacturers are not as popular. Some vape shops have a vape bar where patrons can test out different e-liquids and socialize. The Electronic Cigarette Convention in North America which started in 2013, is an annual show where companies and consumers meet up.
A subclass of vapers configure their atomizers to produce large amounts of vapor by using low-resistance heating coils. This practice is called "cloud-chasing" By using a coil with very low resistance, the batteries are stressed to a potentially unsafe extent. This could present a risk of dangerous battery failures. As vaping comes under increased scrutiny, some members of the vaping community have voiced their concerns about cloud-chasing, claiming the practice gives vapers a bad reputation when doing it in public. The Oxford Dictionaries' word of the year for 2014 was "vape".Main articles: Regulation of electronic cigarettes and List of vaping bans in the United States A no smoking or vaping sign from the US.
Regulation of e-cigarettes varies across countries and states, ranging from no regulation to banning them entirely. Others have introduced strict restrictions and some have licensed devices as medicines such as in the UK. As of 2015[update], around two thirds of major nations have regulated e-cigarettes in some way. Because of the potential relationship with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries. The companies that make e-cigarettes have been pushing for laws that support their interests. In 2016 the US Department of Transportation banned the use of e-cigarettes on commercial flights. This regulation applies to all flights to and from the US.
The legal status of e-cigarettes is currently pending in many countries. Many countries such as Brazil, Singapore, the Seychelles, Uruguay, and Norway have banned e-cigarettes. In Canada, they are technically illegal to sell, as no nicotine-containing e-fluid is approved by Health Canada, but this is generally unenforced and they are commonly available for sale Canada-wide. In the US and the UK, the use and sale to adults of e-cigarettes are legal.:US:UK As of August 8, 2016, the FDA extended its regulatory power to include e-cigarettes. Under this ruling the FDA will evaluate certain issues, including ingredients, product features and health risks, as well their appeal to minors and non-users. The FDA rule also bans access to minors. A photo ID is required to buy e-cigarettes, and their sale in all-ages vending machines is not permitted. In May 2016 the FDA used its authority under the Family Smoking Prevention and Tobacco Control Act to deem e-cigarette devices and e-liquids to be tobacco products, which meant it intended to regulate the marketing, labelling, and manufacture of devices and liquids; vape shops that mix e-liquids or make or modify devices were considered manufacturing sites that needed to register with FDA and comply with good manufacturing practice regulation. E-cigarette and tobacco companies have recruited lobbyists in an effort to prevent the FDA from evaluating e-cigarette products or banning existing products already on the market.
In February 2014 the European Parliament passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging. In April 2014 the FDA published proposed regulations for e-cigarettes along similar lines. In the US some states tax e-cigarettes as tobacco products, and some state and regional governments have broadened their indoor smoking bans to include e-cigarettes. As of 9 October 2015, at least 48 states and 2 territories banned e-cigarette sales to minors.
E-cigarettes have been listed as drug delivery devices in several countries because they contain nicotine, and their advertising has been restricted until safety and efficacy clinical trials are conclusive. Since they do not contain tobacco, television advertising in the US is not restricted. Some countries have regulated e-cigarettes as a medical product even though they have not approved them as a smoking cessation aid. A 2014 review stated the emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public and recommended that e-cigarettes should be regulated to protect consumers. It added, "heavy regulation by restricting access to e-cigarettes would just encourage continuing use of much unhealthier tobacco smoking." A 2014 review said these products should be considered for regulation in view of the "reported adverse health effects".
A 2014 review said, "the e-cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to promote cigarettes in the 1950s and 1960s." E-cigarettes and nicotine are regularly promoted as safe and beneficial in the media and on brand websites. While advertising of tobacco products is banned in most countries, television and radio e-cigarette advertising in some countries may be indirectly encouraging traditional cigarette smoking. There is no evidence that the cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some claiming to want to cooperate in "harm reduction". In the US, six large e-cigarette businesses spent $59.3 million on promoting e-cigarettes in 2013. Easily circumvented age verification at company websites enables young people to access and be exposed to marketing for e-cigarettes.
A national US television advertising campaign starred Steven Dorff exhaling a "thick flume" of what the ad describes as "vapor, not tobacco smoke", exhorting smokers with the message "We are all adults here, it's time to take our freedom back." The ads, in a context of longstanding prohibition of tobacco advertising on TV, were criticized by organizations such as Campaign for Tobacco-Free Kids as undermining anti-tobacco efforts. Cynthia Hallett of Americans for Non-Smokers' Rights described the US advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable". University of Pennsylvania communications professor Joseph Cappella stated that the setting of the ad near an ocean was meant to suggest an association of clean air with the nicotine product. In 2012 and 2013, e-cigarette companies advertised to a large television audience in the US which included 24 million youth. The channels on which e-cigarette advertising reached the largest numbers of youth (ages 12–17) were AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.
A 2014 review said e-cigarettes are aggressively promoted, mostly via the internet, as a healthy alternative to smoking in the US.Celebrity endorsements are used to encourage e-cigarette use. "Big tobacco" markets e-cigarettes to young people, with industry strategies including cartoon characters and candy flavors to sell e-cigarettes. E-cigarette companies commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as scientists have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum. The assertion that e-cigarette emit "only water vapor" is false because the evidence indicates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and organic volatile compounds, in addition to particulates.Vaping stand, London shopping centre.
The number of e-cigarettes sold increased every year from 2003 to 2015, when a slowdown in the growth in usage occurred in both the US and the UK. As of 2014[update] there were at least 466 e-cigarette brands. Worldwide e-cigarette sales in 2014 were around US$7 billion. Approximately 30–50% of total e-cigarettes sales are handled on the internet.
As of 2015[update] most e-cigarette devices were made in China, mainly in Shenzhen. Chinese companies' market share of e-liquid is low.
In the US, tobacco producers have a significant share of the e-cigarette market. As of 2015[update], 80% of all e-cigarette sales in convenience stores in the U.S. were products made by tobacco companies. According to Nielsen Holdings, convenience store e-cigarette sales in the US went down for the first time during the four-week period ending on 10 May 2014. Wells Fargo analyst Bonnie Herzog attributes this decline to a shift in consumers' behavior, buying more specialized devices or what she calls "vapor/tank/mods (VTMs)" that are not tracked by Nielsen. Wells Fargo estimated that VTMs accounted for 57% of the 3.5 billion dollar market in the US for vapor products in 2015. In 2014, the Smoke-Free Alternatives Trade Association estimated that there were 35,000 vape shops in the US, more than triple the number a year earlier. However the 2015 slowdown in market growth affected VTMs as well.
In Canada, e-cigarettes had an estimated value of 140 million CAD in 2015. There are numerous e-cigarette retail shops in Canada. A 2014 audit of retailers in four Canadian cities found that 94% of grocery stores, convenience stores, and tobacconist shops which sold e-cigarettes sold nicotine-free varieties only, while all vape shops stocked at least one nicotine-containing product.
In the UK in 2015 the "most prominent brands of cigalikes" were owned by tobacco companies, but except for one model all the tank types came from "non-tobacco industry companies". However some tobacco industry products, while using prefilled cartridges, resemble tank models.
France's electronic cigarette market was estimated by Groupe Xerfi to be €130 million in 2015. Additionally, France's e-liquid market was estimated at €265 million. In December 2015, there were 2,400 vape shops in France, 400 fewer than in March of the same year. Industry organization Fivape said the reduction was due to consolidation, not to reduced demand.
Other devices to deliver inhaled nicotine have been developed. They aim to mimic the ritual and behavioral aspects of traditional cigarettes.
British American Tobacco, through their subsidiary Nicoventures, licensed a nicotine delivery system based on existing asthma inhaler technology from UK-based healthcare company Kind Consumer. In September 2014 a product based on this named Voke obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.
Philip Morris International (PMI) bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University. The technology is based on the chemical reaction between pyruvic acid and nicotine, which produces an inhalable nicotine pyruvate vapor.
PAX Labs has developed vaporizers that heats the leaves of tobacco to deliver nicotine in a vapor. On 1 June 2015, they introduced Juul a different type of e-cigarette which delivers 10 times as much nicotine as other e-cigarettes, equivalent to an actual cigarette puff.
BLOW started selling e-hookahs, an electronic version of the hookah, in 2014. Several companies including Canada's Eagle Energy Vapor are selling caffeine-based e-cigarettes instead of nicotine.
- ^ a b Sullum, Jacob (27 Aug 2015), "Wacky British Idea: Why Not Tell The Truth About E-Cigarettes?", Forbes
- ^ a b c d WHO (2014), Electronic nicotine delivery systems: FCTC/COP/6/10 Rev.1 (PDF), Moscow: World Health Organization, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Sixth session, 13–18 October 2014
- ^ a b "Cambridge study raises fears over e-cigarette adverts for children", Cambridge News, 18 Jan 2016
- ^ Lam on behalf of the Asian-Pacific Society of Respirology; et al. (2014), "Electronic cigarettes: ‘Vaping’ has unproven benefits and potential harm", Respirology, 19: 945–947, PMID 25196968, doi:10.1111/resp.12374
- ^ a b Millar et al. (20 Mar 2016), "Consumer Product Safety Commission Gains New Authority Over Some Nicotine-Containing E-Liquid Packages", The National Law Review CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h i j McRobbie, Hayden; Bullen, Chris; Hartmann-Boyce, Jamie; Hajek, Peter; McRobbie, Hayden (2014). "Electronic cigarettes for smoking cessation and reduction". The Cochrane Library. 12: CD010216. PMID 25515689. doi:10.1002/14651858.CD010216.pub2.
- ^ V.Courtney Broaddus, Robert C Mason, Joel D Ernst, Talmadge E King Jr., Stephen C. Lazarus, John F. Murray, Jay A. Nadel, Arthur Slutsky, Michael Gotway (2015). Murray & Nadel's Textbook of Respiratory Medicine. Elsevier Health Sciences. p. 820. ISBN 0323261930. CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h Ebbert, Jon O.; Agunwamba, Amenah A.; Rutten, Lila J. (2015). "Counseling Patients on the Use of Electronic Cigarettes". Mayo Clinic Proceedings. 90 (1): 128–134. ISSN 0025-6196. PMID 25572196. doi:10.1016/j.mayocp.2014.11.004.
- ^ a b c d e f g Siu, A.L. (22 September 2015). "Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement.". Annals of Internal Medicine. 163: 622–34. PMID 26389730. doi:10.7326/M15-2023.
- ^ a b Harrell, P.T.; Simmons, V.N.; Correa, J.B.; Padhya, T.A.; Brandon, T.H. (4 June 2014). "Electronic Nicotine Delivery Systems ("E-cigarettes"): Review of Safety and Smoking Cessation Efficacy.". Otolaryngology—head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 151: 381–393. PMC 4376316 . PMID 24898072. doi:10.1177/0194599814536847.
- ^ Golub, Justin S.; Samy, Ravi N. (2015). "Preventing or reducing smoking-related complications in otologic and neurotologic surgery". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (5): 334–340. ISSN 1068-9508. PMID 26339963. doi:10.1097/MOO.0000000000000184.
- ^ a b c d McNeill, A. (August 2015). "E-cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. pp. 77–78.
- ^ a b c d e f Rahman MA, Hann N, Wilson A, Worrall-Carter L (2014). "Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues". Tob Induc Dis. 12 (1): 21. PMC 4350653 . PMID 25745382. doi:10.1186/1617-9625-12-21. CS1 maint: Uses authors parameter (link)
- ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016. Retrieved 29 May 2016.
- ^ a b c d Royal College of Physicians. "Nicotine without smoke: Tobacco harm reduction". rcplondon.ac.uk. Retrieved 8 May 2016.
- ^ a b c "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. US Food and Drug Administration. 81 (90): 28974–29106. 10 May 2016.
- ^ Nutt, DJ; Phillips, LD; Balfour, D; Curran, HV; Dockrell, M; Foulds, J; Fagerstrom, K; Letlape, K; Milton, A; Polosa, R; Ramsey, J; Sweanor, D (2014). "Estimating the harms of nicotine-containing products using the MCDA approach.". European Addiction Research. 20 (5): 218–25. PMID 24714502. doi:10.1159/000360220.
- ^ a b c Caponnetto P.; Russo C.; Bruno C.M.; Alamo A.; Amaradio M.D.; Polosa R. (Mar 2013). "Electronic cigarette: a possible substitute for cigarette dependence". Monaldi archives for chest disease. 79 (1): 12–19. PMID 23741941. doi:10.4081/monaldi.2013.104.
- ^ a b c d e f g h i j k WHO. "Electronic nicotine delivery systems" (PDF). pp. 1–13. Retrieved 28 August 2014.
- ^ a b "E-Cigarette Use Among Youth and Young Adults A Report of the Surgeon General: Fact Sheet" (PDF). United States Department of Health and Human Services. Surgeon General of the United States. 2016. This article incorporates text from this source, which is in the public domain.
- ^ Soneji, S; Barrington-Trimis, J; Wills, T (26 June 2017). "Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults, A Systematic Review and Meta-analysis". JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1488.
- ^ McNeill, A, PH. "Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note". gov.uk. Public Health England. Retrieved 27 May 2016.
- ^ a b c d e f g h i j k l m n o p q r s t u Grana, R; Benowitz, N; Glantz, SA (13 May 2014). "E-cigarettes: a scientific review.". Circulation. 129 (19): 1972–86. PMC 4018182 . PMID 24821826. doi:10.1161/circulationaha.114.007667.
- ^ a b c d e f Cheng, T. (2014). "Chemical evaluation of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii11–ii17. ISSN 0964-4563. PMC 3995255 . PMID 24732157. doi:10.1136/tobaccocontrol-2013-051482.
- ^ a b c d e f g h i Hajek, P.; Etter, J.F.; Benowitz, N.; Eissenberg, T.; McRobbie, H. (31 July 2014). "Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit". Addiction (Abingdon, England). 109 (11): 1801–10. PMC 4487785 . PMID 25078252. doi:10.1111/add.12659.
- ^ a b c d e f g h Britton, John; Bogdanovica, Ilze (15 May 2014). "Electronic cigarettes – A report commissioned by Public Health England" (PDF). Public Health England.
- ^ a b c d e f g Farsalinos, K.E.; Polosa, R. (2014). "Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review". Therapeutic Advances in Drug Safety. 5 (2): 67–86. ISSN 2042-0986. PMC 4110871 . PMID 25083263. doi:10.1177/2042098614524430.
- ^ a b c Burstyn, Igor (2014). "Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks". BMC Public Health. 14 (1): 18. ISSN 1471-2458. PMC 3937158 . PMID 24406205. doi:10.1186/1471-2458-14-18.
- ^ a b c "E-cigarettes: an emerging public health consensus". UK: Public Health England. 2015.
- ^ a b c d e f g Barbara Demick (25 April 2009). "A high-tech approach to getting a nicotine fix". Los Angeles Times.
- ^ a b c Alawsi, F.; Nour, R.; Prabhu, S. (2015). "Are e-cigarettes a gateway to smoking or a pathway to quitting?". BDJ. 219 (3): 111–115. ISSN 0007-0610. PMID 26271862. doi:10.1038/sj.bdj.2015.591.
- ^ a b c d e f Rom, Oren; Pecorelli, Alessandra; Valacchi, Giuseppe; Reznick, Abraham Z. (2014). "Are E-cigarettes a safe and good alternative to cigarette smoking?". Annals of the New York Academy of Sciences. 1340 (1): 65–74. ISSN 0077-8923. PMID 25557889. doi:10.1111/nyas.12609.
- ^ a b "E-cigarette use triples among middle and high school students in just one year". CDC. Retrieved 15 December 2015.
- ^ a b c "Use of electronic cigarettes (vapourisers) among adults in Great Britain" (PDF). ASH UK. May 2015.
- ^ a b Kim, Ki-Hyun; Kabir, Ehsanul; Jahan, Shamin Ara (2016). "Review of electronic cigarettes as tobacco cigarette substitutes: their potential human health impact". Journal of Environmental Science and Health, Part C: 00–00. ISSN 1059-0501. PMID 27635466. doi:10.1080/10590501.2016.1236604.
- ^ a b "Questions & Answers: New rules for tobacco products". European Commission. 26 February 2014.
- ^ a b "FDA's New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products". US Department of Health and Human Services. US Food and Drug Administration. 12 August 2016.
- ^ a b "Backgrounder on WHO report on regulation of e-cigarettes and similar products". 26 August 2014. Retrieved 2 June 2015.
- ^ editor (13 Aug 2015), "Tasty E-Cigs Popular, Scientifically Uncertain", WGCU News NPR
- ^ Kahn, Steven (18 Dec 2015), "The Best Electronic Cigarettes For Beginners", The Gazette Review
- ^ Keenan et al. (9 Sep 2015), "Vape Culture Attracts Teens, Poses Harmful Risks", The Huffington Post CS1 maint: Uses authors parameter (link)
- ^ "Public consultation on legislation in relation to the sale of tobacco products and non-medicinal nicotine delivery systems, including e-cigarettes". Department of Health (Ireland). 2 December 2014. Retrieved 4 October 2016.
- ^ Michael Felberbaum (11 June 2013). "Marlboro Maker To Launch New Electronic Cigarette". The Huffington Post.
- ^ a b Schraufnagel, Dean E.; Blasi, Francesco; Drummond, M. Bradley; Lam, David C. L.; Latif, Ehsan; Rosen, Mark J.; Sansores, Raul; Van Zyl-Smit, Richard (2014). "Electronic Cigarettes. A Position Statement of the Forum of International Respiratory Societies". American Journal of Respiratory and Critical Care Medicine. 190 (6): 611–618. ISSN 1073-449X. PMID 25006874. doi:10.1164/rccm.201407-1198PP.
- ^ a b c Mickle, Tripp (17 November 2015). "E-cig sales rapidly lose steam". E-Cigarette Sales Rapidly Lose Steam. Retrieved 6 December 2015.
- ^ a b West, Robert; Beard, Emma; Brown, Jamie (10 August 2015). "Electronic cigarettes in England – latest trends (STS140122)". Smoking in England. Retrieved 6 December 2015.
- ^ a b c d e Carroll Chapman, SL; Wu, LT (18 Mar 2014). "E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.". Journal of Psychiatric Research. 54: 43–54. PMC 4055566 . PMID 24680203. doi:10.1016/j.jpsychires.2014.03.005.
- ^ a b c Bullen, Christopher (2014). "Electronic Cigarettes for Smoking Cessation". Current Cardiology Reports. 16 (11): 538. ISSN 1523-3782. PMID 25303892. doi:10.1007/s11886-014-0538-8.
- ^ a b Born, H.; Persky, M.; Kraus, D.H.; Peng, R.; Amin, M.R.; Branski, R.C. (2015). "Electronic Cigarettes: A Primer for Clinicians". Otolaryngology – Head and Neck Surgery. 153: 5–14. ISSN 0194-5998. PMID 26002957. doi:10.1177/0194599815585752.
- ^ a b c d e f g h i Pepper, J. K.; Brewer, N. T. (2013). "Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review". Tobacco Control. 23 (5): 375–384. ISSN 0964-4563. PMC 4520227 . PMID 24259045. doi:10.1136/tobaccocontrol-2013-051122.
- ^ Suter, Melissa A.; Mastrobattista, Joan; Sachs, Maike; Aagaard, Kjersti (2015). "Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (3): 186–195. ISSN 1542-0752. PMC 4830434 . PMID 25366492. doi:10.1002/bdra.23333.
- ^ Franck, C.; Budlovsky, T.; Windle, S.B.; Filion, K. B.; Eisenberg, M.J. (2014). "Electronic Cigarettes in North America: History, Use, and Implications for Smoking Cessation". Circulation. 129 (19): 1945–1952. ISSN 0009-7322. PMID 24821825. doi:10.1161/CIRCULATIONAHA.113.006416.
- ^ Charlotte A. Schoenborn, Renee M. Gindi (October 2015). "Electronic Cigarette Use Among Adults: United States, 2014" (PDF). Centers for Disease Control and Prevention. pp. 1–8. CS1 maint: Uses authors parameter (link)
- ^ a b c d Delnevo, Cristine D.; Giovenco, Daniel P.; Steinberg, Michael B.; Villanti, Andrea C.; Pearson, Jennifer L.; Niaura, Raymond S.; Abrams, David B. (2 November 2015). "Patterns of Electronic Cigarette Use Among Adults in the United States". Nicotine & Tobacco Research. 18: ntv237. doi:10.1093/ntr/ntv237.
- ^ Volkow, Nora (August 2015). "Teens Using E-cigarettes More Likely to Start Smoking Tobacco". National Institute on Drug Abuse.
- ^ a b Lauterstein, Dana; Hoshino, Risa; Gordon, Terry; Watkins, Beverly-Xaviera; Weitzman, Michael; Zelikoff, Judith (2014). "The Changing Face of Tobacco Use Among United States Youth". Current Drug Abuse Reviews. 7 (1): 29–43. ISSN 1874-4737. PMC 4469045 . PMID 25323124. doi:10.2174/1874473707666141015220110.
- ^ a b Hildick-Smith, Gordon J.; Pesko, Michael F.; Shearer, Lee; Hughes, Jenna M.; Chang, Jane; Loughlin, Gerald M.; Ipp, Lisa S. (2015). "A Practitioner's Guide to Electronic Cigarettes in the Adolescent Population". Journal of Adolescent Health. 57: 574–9. ISSN 1054-139X. PMID 26422289. doi:10.1016/j.jadohealth.2015.07.020.
- ^ Sabrina Tavernise (17 April 2015). "Use of e-cigarettes rising sharply among teenagers". Boston Globe.
- ^ a b c d Schraufnagel, Dean E. (2015). "Electronic Cigarettes: Vulnerability of Youth". Pediatric Allergy, Immunology, and Pulmonology. 28 (1): 2–6. ISSN 2151-321X. PMC 4359356 . PMID 25830075. doi:10.1089/ped.2015.0490.
- ^ "Monitoring the Future Survey, Overview of Findings 2015". National Institute on Drug Abuse. Retrieved 10 March 2016.
- ^ Arrazola, RA; Neff, LJ; Kennedy, SM; Holder-Hayes, E; Jones, CD (14 November 2014). "Tobacco Use Among Middle and High School Students — United States, 2013". MMWR Morb. Mortal. Wkly. Rep. 63 (45): 1021–1026. PMID 24699766.
- ^ a b Cooke, Andrew; Fergeson, Jennifer; Bulkhi, Adeeb; Casale, Thomas B. (2015). "The Electronic Cigarette: The Good, the Bad, and the Ugly". The Journal of Allergy and Clinical Immunology: In Practice. 3 (4): 498–505. ISSN 2213-2198. PMID 26164573. doi:10.1016/j.jaip.2015.05.022.
- ^ Centers for Disease Control and Prevention (CDC) (November 2013). "Tobacco product use among middle and high school students—United States, 2011 and 2012". MMWR Morb. Mortal. Wkly. Rep. 62 (45): 893–7. PMID 24226625.
- ^ a b McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. Retrieved 19 August 2015.
- ^ a b c "Use of electronic cigarettes in Great Britain" (PDF). ASH. ASH. July 2014. Retrieved 18 September 2014.
- ^ "Over 2 million Britons now regularly use electronic cigarettes". ASH UK. 28 April 2014. Retrieved 30 May 2014.
- ^ McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. pp. 31–34. Retrieved 25 August 2015.
- ^ Moore, G. F.; Littlecott, H. J.; Moore, L.; Ahmed, N.; Holliday, J. (2014). "E-cigarette use and intentions to smoke among 10-11-year-old never-smokers in Wales". Tobacco Control. 25: 147–52. ISSN 0964-4563. PMC 4789807 . PMID 25535293. doi:10.1136/tobaccocontrol-2014-052011.
- ^ a b c "Prévalence, comportements d'achat et d'usage, motivations des utilisateurs de la cigarette électronique" (PDF). Observatoire Français des Drogues et des Toxicomanies. 12 February 2014. Retrieved 28 March 2014.
- ^ a b c Brandon, T.H.; Goniewicz, M.L.; Hanna, N.H.; Hatsukami, D.K.; Herbst, R.S.; Hobin, J.A.; Ostroff, J.S.; Shields, P.G.; Toll, B.A.; Tyne, C.A.; Viswanath, K.; Warren, G.W. (2015). "Electronic Nicotine Delivery Systems: A Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology" (PDF). Clinical Cancer Research. 21: 514–525. ISSN 1078-0432. PMID 25573384. doi:10.1158/1078-0432.CCR-14-2544.
- ^ Zhong, Jieming; Cao, Shuangshuang; Gong, Weiwei; Fei, Fangrong; Wang, Meng (3 May 2016). "Electronic Cigarettes Use and Intention to Cigarette Smoking among Never-Smoking Adolescents and Young Adults: A Meta-Analysis". International Journal of Environmental Research and Public Health. 13 (5): 465. doi:10.3390/ijerph13050465.
- ^ a b "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original on 6 November 2014. CS1 maint: BOT: original-url status unknown (link)
- ^ a b c Grana R.A., Ling P.M. (2014). ""Smoking revolution": a content analysis of electronic cigarette retail websites". Am J Prev Med. 46 (4): 395–403. PMC 3989286 . PMID 24650842. doi:10.1016/j.amepre.2013.12.010. CS1 maint: Uses authors parameter (link)
- ^ a b Tomashefski, A (21 March 2016). "The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review.". Journal of the American Association of Nurse Practitioners. PMID 26997487. doi:10.1002/2327-6924.12358.
- ^ a b c d e Orellana-Barrios, Menfil A.; Payne, Drew; Mulkey, Zachary; Nugent, Kenneth (2015). "Electronic cigarettes-a narrative review for clinicians". The American Journal of Medicine. 128: 674–81. ISSN 0002-9343. PMID 25731134. doi:10.1016/j.amjmed.2015.01.033.
- ^ a b Crowley, Ryan A. (2015). "Electronic Nicotine Delivery Systems: Executive Summary of a Policy Position Paper From the American College of Physicians". Annals of Internal Medicine. 162 (8): 583–4. ISSN 0003-4819. PMID 25894027. doi:10.7326/M14-2481.
- ^ a b c England, Lucinda J.; Bunnell, Rebecca E.; Pechacek, Terry F.; Tong, Van T.; McAfee, Tim A. (2015). "Nicotine and the Developing Human". American Journal of Preventive Medicine. 49: 286–93. ISSN 0749-3797. PMC 4594223 . PMID 25794473. doi:10.1016/j.amepre.2015.01.015.
- ^ a b Linda Bauld; Kathryn Angus; Marisa de Andrade (May 2014). "E-cigarette uptake and marketing" (PDF). Public Health England. pp. 1–19.
- ^ Kong, G.; Morean, M.E.; Cavallo, D.A.; Camenga, D.R.; Krishnan-Sarin, S. (2014). "Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults". Nicotine & Tobacco Research. 17: 847–54. ISSN 1462-2203. PMC 4674436 . PMID 25481917. doi:10.1093/ntr/ntu257.
- ^ "Heart and Stroke Foundation: E-cigarettes in Canada". Heart and Stroke Foundation.
- ^ Kevin Chatham-Stephens (20 October 2014). "Young Children and e-Cigarette Poisoning". Medscape.
- ^ a b Yingst, J. M.; Veldheer, S.; Hrabovsky, S.; Nichols, T. T.; Wilson, S. J.; Foulds, J. (2015). "Factors associated with electronic cigarette users' device preferences and transition from first generation to advanced generation devices.". Nicotine Tob Res. 17: 1242–6. ISSN 1462-2203. PMC 4592341 . PMID 25744966. doi:10.1093/ntr/ntv052.
- ^ a b Sanford Z, Goebel L (2014). "E-cigarettes: an up to date review and discussion of the controversy". W V Med J. 110 (4): 10–5. PMID 25322582. CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h i Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015-08-01). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. ISSN 1660-4601. PMC 4555324 . PMID 26308021. doi:10.3390/ijerph120809988.
- ^ Abuse, National Institute on Drug. "Electronic Cigarettes (e-Cigarettes)". drugabuse.gov. Retrieved 2016-01-27.
- ^ Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015-08-01). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. ISSN 1661-7827. PMC 4555324 . PMID 26308021. doi:10.3390/ijerph120809988.
- ^ "Electronic Cigarette Fires and Explosions" (PDF). U.S. Fire Administration. 2014. pp. 1–11.
- ^ "What is an e-Cigarette MOD E-cig 101". 19 February 2014.
- ^ "Vaper Talk – The Vaper's Glossary". Spinfuel eMagazine. 5 July 2013. Retrieved 18 November 2014.
- ^ a b c Rowell, Temperance R.; Tarran, Robert (2015). "Will Chronic E-Cigarette Use Cause Lung Disease?". American Journal of Physiology. Lung Cellular and Molecular Physiology. 309: ajplung.00272.2015. ISSN 1040-0605. PMC 4683316 . PMID 26408554. doi:10.1152/ajplung.00272.2015.
- ^ a b c Caponnetto, Pasquale; Campagna, Davide; Papale, Gabriella; Russo, Cristina; Polosa, Riccardo (2012). "The emerging phenomenon of electronic cigarettes". Expert Review of Respiratory Medicine. 6 (1): 63–74. ISSN 1747-6348. PMID 22283580. doi:10.1586/ers.11.92.
- ^ Glasser, A. M.; Cobb, C. O.; Teplitskaya, L.; Ganz, O.; Katz, L.; Rose, S. W.; Feirman, S.; Villanti, A. C. (2015). "Electronic nicotine delivery devices, and their impact on health and patterns of tobacco use: a systematic review protocol". BMJ Open. 5 (4): e007688–e007688. ISSN 2044-6055. PMC 4420972 . PMID 25926149. doi:10.1136/bmjopen-2015-007688.
- ^ a b c d Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, Voudris V (2014). "Nicotine absorption from electronic cigarette use: Comparison between first and new-generation devices". Scientific Reports. 4: 4133. PMC 3935206 . PMID 24569565. doi:10.1038/srep04133.
- ^ a b c Bhatnagar, A.; Whitsel, L. P.; Ribisl, K. M.; Bullen, C.; Chaloupka, F.; Piano, M.R.; Robertson, R. M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "AHA Policy Statement - Electronic Cigarettes". Circulation. 130 (16): 1418–1436. PMID 25156991. doi:10.1161/cir.0000000000000107. Archive
- ^ Hayden McRobbie (2014). "Electronic cigarettes" (PDF). National Centre for Smoking Cessation and Training. pp. 1–16.
- ^ Konstantinos Farsalinos. "Electronic cigarette evolution from the first to fourth generation and beyond" (PDF). gfn.net.co. Global Forum on Nicotine. p. 23. Retrieved 23 September 2015.
- ^ a b c d e Garner, Charles; Stevens, Robert (February 2014). "A Brief Description of History, Operation and Regulation" (PDF). Coresta. Retrieved 21 February 2016.
- ^ a b c Oh, Anne Y.; Kacker, Ashutosh (December 2014). "Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes?: Review on e-cigarette vapor versus tobacco smoke". The Laryngoscope. 124 (12): 2702–2706. PMID 25302452. doi:10.1002/lary.24750.
- ^ Jimenez Ruiz, CA; Solano Reina, S; de Granda Orive, JI; Signes-Costa Minaya, J; de Higes Martinez, E; Riesco Miranda, JA; Altet Gómez, N; Lorza Blasco, JJ; Barrueco Ferrero, M; de Lucas Ramos, P (August 2014). "The electronic cigarette. Official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes.". Archivos de bronconeumologia. 50 (8): 362–7. PMID 24684764. doi:10.1016/j.arbres.2014.02.006.
- ^ a b John Reid Blackwell. "Avail Vapor offers glimpse into the 'art and science' of e-liquids". Richmond Times-Dispatch. Retrieved 23 November 2015.
- ^ E-Liquid Manufacturing Standards (PDF). US: AMERICAN E-LIQUID MANUFACTURING STANDARDS ASSOCIATION (AEMSA). 2015. pp. 1–13.
- ^ "More than a quarter-million youth who had never smoked a cigarette used e-cigarettes in 2013". Centers for Disease Control and Prevention. Retrieved 8 July 2015.
- ^ a b c Framework Convention Alliance on Tobacco Control. "FCA Policy briefing Electronic Nicotine Delivery Systems" (PDF). fctc.org. Retrieved 2 March 2016.
- ^ a b "Electronic Cigarettes (e-Cigarettes)". US Food and Drug Administration. Retrieved 6 November 2014.
- ^ a b c d McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 15. Retrieved 24 August 2015.
- ^ National Centre for Smoking Cessation and Training. "Electronic cigarettes: A briefing for stop smoking services". ncsct.co.uk. Retrieved 2 March 2016.
- ^ a b WHO (August 2016). "Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS)" (PDF). pp. 1–11.
- ^ "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. Retrieved 6 November 2014.
- ^ a b McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 76. Retrieved 19 August 2015.
- ^ a b "Electronic cigarettes". Smokefree NHS. Are e-cigarettes safe to use?. Retrieved 28 October 2015.
- ^ "Stop smoking treatments". UK National Health Service. Retrieved 6 November 2014.
- ^ Royal College of Physicians. "Promote e-cigarettes widely as substitute for smoking says new RCP report". rcplondon.ac.uk. Retrieved 7 May 2017.
- ^ "E-cigarette Ads and Youth". Centers for Disease Control and Prevention. Retrieved 26 January 2016.
- ^ "Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions". United States Preventive Services Task Force. Retrieved 3 March 2016.
- ^ "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. August 2015. Retrieved 19 April 2016.
- ^ Farber HJ, Walley SC, Groner JA, Nelson KE (2015). "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" (PDF). Pediatrics. 136 (5): 1008–1017. ISSN 0031-4005. PMID 26504137. doi:10.1542/peds.2015-3108. CS1 maint: Multiple names: authors list (link)
- ^ a b c d e Bhatnagar, A.; Whitsel, L.P.; Ribisl, K.M.; Bullen, C.; Chaloupka, F.; Piano, M.R.; Robertson, R.M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "Electronic Cigarettes: A Policy Statement From the American Heart Association". Circulation. 130 (16): 1418–1436. PMID 25156991. doi:10.1161/CIR.0000000000000107.
- ^ "CDC launches powerful new ads in 'Tips From Former Smokers' campaign". Centers for Disease Control and Prevention. 26 March 2015.
- ^ Knight-West, O; Bullen, C (2016). "E-cigarettes for the management of nicotine addiction.". Substance Abuse and Rehabilitation. 7: 111–8. PMC 4993405 . PMID 27574480. doi:10.2147/SAR.S94264.
- ^ Glasser, AM; Collins, L; Pearson, JL; Abudayyeh, H; Niaura, RS; Abrams, DB; Villanti, AC (30 November 2016). "Overview of Electronic Nicotine Delivery Systems: A Systematic Review.". American journal of preventive medicine. PMID 27914771. doi:10.1016/j.amepre.2016.10.036.
- ^ El Dib, R; Suzumura, EA; Akl, EA; Gomaa, H; Agarwal, A; Chang, Y; Prasad, M; Ashoorion, V; Heels-Ansdell, D; Maziak, W; Guyatt, G (23 February 2017). "Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis.". BMJ Open. 7 (2): e012680. PMC 5337697 . PMID 28235965. doi:10.1136/bmjopen-2016-012680.
- ^ a b c Kalkhoran, Sara; Glantz, Stanton A (2016). "E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis". The Lancet Respiratory Medicine. 4: 116–128. PMID 26776875. doi:10.1016/s2213-2600(15)00521-4.
- ^ a b c Rahman, Muhammad Aziz (30 March 2015). "E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis". PLOS ONE. 10: e0122544. PMC 4378973 . PMID 25822251. doi:10.1371/journal.pone.0122544.
- ^ Khoudigian, S; Devji, T; Lytvyn, L; Campbell, K; Hopkins, R; O'Reilly, D (29 January 2016). "The efficacy and short-term effects of electronic cigarettes as a method for smoking cessation: a systematic review and a meta-analysis.". International journal of public health. 61: 257–67. PMID 26825455. doi:10.1007/s00038-016-0786-z.
- ^ Malas, M; van der Tempel, J; Schwartz, R; Minichiello, A; Lightfoot, C; Noormohamed, A; Andrews, J; Zawertailo, L; Ferrence, R (25 April 2016). "Electronic Cigarettes for Smoking Cessation: A Systematic Review.". Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco: ntw119. PMID 27113014. doi:10.1093/ntr/ntw119.
- ^ Orellana-Barrios, MA; Payne, D; Medrano-Juarez, RM; Yang, S; Nugent, K (October 2016). "Electronic Cigarettes for Smoking Cessation.". The American journal of the medical sciences. 352 (4): 420–426. PMID 27776725. doi:10.1016/j.amjms.2016.07.013.
- ^ a b Hartmann-Boyce, Jamie; McRobbie, Hayden; Bullen, Chris; Begh, Rachna; Stead, Lindsay F; Hajek, Peter; Hartmann-Boyce, Jamie (2016). "Electronic cigarettes for smoking cessation". Cochrane Database Syst Rev. 9: CD010216. PMID 27622384. doi:10.1002/14651858.CD010216.pub3.
- ^ a b c d e f Cahn, Z.; Siegel, M. (February 2011). "Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes?". Journal of public health policy. 32 (1): 16–31. PMID 21150942. doi:10.1057/jphp.2010.41.
- ^ Saitta, D.; Ferro, G.A.; Polosa, R. (3 February 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic Advances in Chronic Disease. 5 (2): 6. PMC 3926346 . PMID 24587890. doi:10.1177/2040622314521271.
- ^ Weaver, Michael; Breland, Alison; Spindle, Tory; Eissenberg, Thomas (2014). "Electronic Cigarettes". Journal of Addiction Medicine. 8 (4): 234–240. ISSN 1932-0620. PMC 4123220 . PMID 25089953. doi:10.1097/ADM.0000000000000043.
- ^ Franck, C; Filion, KB; Kimmelman, J; Grad, R; Eisenberg, MJ (17 May 2016). "Ethical considerations of e-cigarette use for tobacco harm reduction.". Respiratory Research. 17 (1): 53. PMC 4869264 . PMID 27184265. doi:10.1186/s12931-016-0370-3.
- ^ a b c Drummond, M.B.; Upson, D (February 2014). "Electronic cigarettes: Potential harms and benefits". Annals of the American Thoracic Society. 11 (2): 236–42. PMID 24575993. doi:10.1513/annalsats.201311-391fr.
- ^ McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 65. Retrieved 20 August 2015.
- ^ a b c d Saitta, D; Ferro, GA; Polosa, R (Mar 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic advances in chronic disease. 5 (2): 50–61. PMC 3926346 . PMID 24587890. doi:10.1177/2040622314521271.
- ^ a b Nowak D, Jörres RA, Rüther T (2014). "E-cigarettes—prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. PMC 4047602 . PMID 24882626. doi:10.3238/arztebl.2014.0349. CS1 maint: Uses authors parameter (link)
- ^ "BMA calls for stronger regulation of e-cigarettes" (PDF). British Medical Association. Retrieved 18 November 2013.
- ^ "Principles to Guide AAPHP Tobacco Policy". American Association of Public Health Physicians. Retrieved 31 July 2013.
- ^ a b c Edgar, Julie. "E-Cigarettes: Expert Q&A With the CDC". WebMD. Retrieved 17 November 2013.
- ^ Detailed reference list is located on a separate image page.
- ^ Cancer Research UK. "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). cancerresearchuk.org. Retrieved 20 March 2016.
- ^ Odum, L.E.; O'Dell, K.A.; Schepers, J.S. (December 2012). "Electronic cigarettes: do they have a role in smoking cessation?". Journal of pharmacy practice. 25 (6): 611–4. PMID 22797832. doi:10.1177/0897190012451909.
- ^ O'Connor, R.J. (March 2012). "Non-cigarette tobacco products: what have we learnt and where are we headed?". Tobacco control. 21 (2): 181–90. PMC 3716250 . PMID 22345243. doi:10.1136/tobaccocontrol-2011-050281.
- ^ Farsalinos, Konstantinos E; Le Houezec, Jacques (29 September 2015). "Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)". Risk Management and Healthcare Policy. 8: 157–167. PMC 4598199 . PMID 26457058. doi:10.2147/RMHP.S62116.
- ^ Polosa R, Campagna D, Caponnetto P (2015). "What to advise to respiratory patients intending to use electronic cigarettes". Discov Med. 20 (109): 155–61. PMID 26463097.
- ^ Polosa R (2015). "Electronic cigarette use and harm reversal: emerging evidence in the lung". BMC Med. 13: 54. PMC 4365531 . PMID 25857426. doi:10.1186/s12916-015-0298-3.
- ^ "The Potential Adverse Health Consequences of Exposure to Electronic Cigarettes and Electronic Nicotine Delivery Systems". Oncology Nursing Forum. 42 (5): 445–446. 2015. ISSN 0190-535X. PMID 26302273. doi:10.1188/15.ONF.445-446.
- ^ a b c Durmowicz, E.L. (2014). "The impact of electronic cigarettes on the paediatric population". Tobacco Control. 23 (Supplement 2): ii41–ii46. ISSN 0964-4563. PMC 3995262 . PMID 24732163. doi:10.1136/tobaccocontrol-2013-051468.
- ^ a b Bertholon, J.F.; Becquemin, M.H.; Annesi-Maesano, I.; Dautzenberg, B. (2013). "Electronic Cigarettes: A Short Review". Respiration. 86: 433–8. ISSN 1423-0356. PMID 24080743. doi:10.1159/000353253.
- ^ McNeill, A, PH. "Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note". gov.uk. Public Health England. Retrieved 27 May 2016.
- ^ a b Polosa, R.; Campagna, D.; Caponnetto, P. (September 2015). "What to advise to respiratory patients intending to use electronic cigarettes". Discovery medicine. 20 (109): 155–61. PMID 26463097.
- ^ Kosmider, Leon; et al. (September 2014). "Carbonyl Compounds in Electronic Cigarette Vapors: Effects of Nicotine Solvent and Battery Output Voltage". Nicotine & Tobacco Research. 16 (10): 1319–1326. ISSN 1462-2203. PMID 24832759. doi:10.1093/ntr/ntu078.
- ^ a b Jerry JM, Collins GB, Streem D (2015). "E-cigarettes: Safe to recommend to patients?". Cleve Clin J Med. 82 (8): 521–6. PMID 26270431. doi:10.3949/ccjm.82a.14054. CS1 maint: Uses authors parameter (link)
- ^ "The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014, Chapter 5 - Nicotine" (PDF). Surgeon General of the United States. 2014. pp. 107–138.
- ^ Benowitz, NL; Fraiman, JB (23 March 2017). "Cardiovascular effects of electronic cigarettes.". Nature Reviews Cardiology. PMID 28332500. doi:10.1038/nrcardio.2017.36.
- ^ Pisinger, Charlotta; Døssing, Martin (December 2014). "A systematic review of health effects of electronic cigarettes". Preventive Medicine. 69: 248–260. PMID 25456810. doi:10.1016/j.ypmed.2014.10.009.
- ^ Chang, H. (2014). "Research gaps related to the environmental impacts of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii54–ii58. ISSN 0964-4563. PMC 3995274 . PMID 24732165. doi:10.1136/tobaccocontrol-2013-051480.
- ^ Public Health England. "E-cigarettes in public places and workplaces: a 5-point guide to policy making". uk.gov. Retrieved 7 May 2017.
- ^ Hess, IM; Lachireddy, K; Capon, A (15 April 2016). "A systematic review of the health risks from passive exposure to electronic cigarette vapour.". Public health research & practice. 26 (2). PMID 27734060. doi:10.17061/phrp2621617.
- ^ "State Health Officer's Report on E-Cigarettes: A Community Health Threat" (PDF). California Department of Public Health, California Tobacco Control Program. January 2015.
- ^ Linda J. Vorvick (2013-08-29). "Nicotine and Tobacco". Medline Plus. Retrieved 2015-05-21.
- ^ Palazzolo, Dominic L. (Nov 2013). "Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review.". Frontiers in Public Health. 1 (56). PMC 3859972 . PMID 24350225. doi:10.3389/fpubh.2013.00056.
- ^ a b Schroeder, M.J.; Hoffman, A.C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. ISSN 0964-4563. PMC 3995273 . PMID 24732160. doi:10.1136/tobaccocontrol-2013-051469.
- ^ a b "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. September 2014. Retrieved 15 October 2014.
- ^ Evans, S.E.; Hoffman, A.C. (2014). "Electronic cigarettes: abuse liability, topography and subjective effects". Tobacco Control. 23 (Supplement 2): ii23–ii29. ISSN 0964-4563. PMC 3995256 . PMID 24732159. doi:10.1136/tobaccocontrol-2013-051489.
- ^ Centers for Disease Control and Prevention, (CDC) (6 September 2013). "Notes from the field: electronic cigarette use among middle and high school students – United States, 2011–2012". MMWR. Morbidity and mortality weekly report. 62 (35): 729–30. PMID 24005229.
- ^ "Teens like different forms of tobacco and nicotine". American Cancer Society. Archived from the original on 20 September 2015. Retrieved 18 August 2015.
- ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013.
- ^ Korioth, Trisha. "E-cigarettes easy to buy, can hook kids on nicotine". The American Academy of Pediatrics. Retrieved 17 November 2013.
- ^ "FDA Warns of Health Risks Posed by E-Cigarettes". FDA. 23 July 2009. Retrieved 17 November 2013—Reviewed 17 September 2013
- ^ Goniewicz, Maciej L.; Hajek, Peter; McRobbie, Hayden (2014). "Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications" (PDF). Addiction. 109 (3): 500–507. ISSN 0965-2140. PMID 24345184. doi:10.1111/add.12410.
- ^ Noah Charney (7 December 2014). "America's vaping revolution: How suspicious should we really be of the e-cigarette craze?". Salon magazine.
- ^ "US Patent 3200819. Smokeless non-tobacco cigarette". Retrieved 29 February 2012.
- ^ a b c Mary Bellis (2015). "Who Invented Electronic Cigarettes?". About.com.
- ^ a b P.H. (17 March 2014). "A case of the vapers". The Economist.
- ^ Julie Beck (13 June 2014). "Schrödinger's Cigarette: Is Electronic Safer?". The Atlantic.
- ^ Millstein, Seth (25 April 2009). "The Push to Ban E-Cigarettes: Where's the Proof?". TimeLine. Archived from the original on 2 July 2015. Retrieved 18 February 2016.
- ^ "Electronic Cigarette Sales on the Rise". WalesOnline. 24 August 2011.
- ^ a b c d Sridi, Nicolas (10 July 2013). "I was sure that the electronic cigarette would be welcomed with open arms". Sciences et Avenir.
- ^ "Electronic Atomization Cigarette". Worldwide.espacenet.com. 22 November 2007.
- ^ a b "Dragonite Sells E-Vapor Business To ITG". Convenient Store Decisions. 21 August 2013.
- ^ Tom Hancock (1 October 2013). "China's e-cigarette inventor fights for financial rewards". Fox News Channel.
- ^ a b c d e f g Michael Grothaus (1 October 2014). "Trading addictions: the inside story of the e-cig modding scene". Engadget.
- ^ a b Annabel Denham (10 June 2013). "Brothers who took a punt on a new market". CityAM. Retrieved 4 April 2014.
- ^ a b c d e f g Mike K (9 June 2015). "What Does The Future Hold For Vaping Technology?". Steve K's Vaping World.
- ^ Akam, Simon (27 May 2015). "Big Tobacco fights back: how the cigarette kings bought the vaping industry". Newsweek. Retrieved 22 February 2016.
- ^ "Kodak moment". The Economist. 28 September 2013. Retrieved 11 March 2014.
- ^ a b Mike Esterl (3 February 2014). "Altria Expands in E-Cigarettes With Green Smoke". The Wall Street Journal. Retrieved 7 March 2014.
- ^ Brian Montopoli (11 June 2013). "Tobacco companies bet on electronic cigarettes". CBS News. Retrieved 16 August 2013.
- ^ Sanchez Manning (29 July 2013). "British American Tobacco enters electronic cigarette market in Britain with the 'Vype'". The Independent.
- ^ Gustafsson, Katarina (2 September 2013). "Imperial Tobacco Agrees to Acquire Dragonite's E-Cigarette Unit". Bloomberg. Retrieved 20 November 2013.
- ^ "Lorillard, Inc. Acquires British-based SKYCIG, Expanding its Electronic Cigarette Business". Retrieved 1 October 2013.
- ^ "Lorillard to Rebrand SKYCIG as blu eCigs". Convenience Store News. 27 March 2014.
- ^ a b "Altria Completes Acquisition of Green Smoke". BusinessWire. 1 April 2014. Retrieved 21 November 2014.
- ^ Gideon Spanier (26 June 2014). "Philip Morris buys e-cigarette maker Nicocigs as it warns of falling profits". The Independent.
- ^ a b "Japan Tobacco's Global Ambitions Lead to Logic Acquisition". Convenience Store News. 30 April 2015.
- ^ Mangan, Dan (15 July 2014). "Feeling blu? E-cig company spun off in major tobacco deal". CNBC.
- ^ Koebler, Jason (25 September 2014). "Big Tobacco Has Officially Lost Its Hold on the E-Cigarette Market". Motherboard. Retrieved 25 February 2016.
- ^ a b c d e Couts, Andrew (13 May 2013). "Inside the world of vapers, the subculture that might save smokers' lives". Digital Trends. Retrieved 20 November 2013.
- ^ Park, Andy (26 August 2013). "The Feed: The subculture around e-cigarettes". SBS World News. Retrieved 20 November 2013.
- ^ Barbeau, Amanda M; Burda, Jennifer; Siegel, Michael (2013). "Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach". Addiction Science & Clinical Practice. 8 (1): 5. ISSN 1940-0640. PMC 3599549 . PMID 23497603. doi:10.1186/1940-0640-8-5.
- ^ a b Eric Larson (25 January 2014). "Pimp My Vape: The Rise of E-Cigarette Hackers". Mashable. Retrieved 22 November 2014.
- ^ Molly Osberg (25 February 2014). "CVape life: welcome to the weird world of e-cig evangelists". The Verge.
- ^ a b McKee, M. (2014). "Electronic cigarettes: peering through the smokescreen" (PDF). Postgraduate Medical Journal. 90 (1069): 607–609. ISSN 0032-5473. PMID 25294933. doi:10.1136/postgradmedj-2014-133029.
- ^ a b Jacobs, Emma; Robinson, Duncan (17 April 2014). "E-cigarettes: no smoke without fear". FT Magazine. Retrieved 11 January 2016.
- ^ Tom Gara (14 April 2014). "Are E-Cigarettes Losing Ground in the Vapor Market?". The Wall Street Journal.
- ^ Sottile, Leah (8 October 2014). "The Right to Vape". The Atlantic. Retrieved 28 February 2016.
- ^ Gavin Haynes (22 April 2015). "Daft vapers: the competitive world of e-cigarette smoking". The Guardian.
- ^ Mike Esterl (29 May 2014). "'Vaporizers' Are the New Draw in E-Cigarettes". The Wall Street Journal.
- ^ Staff (13 February 2014). "Generation V E-Cigarettes and Vape Bar aims to convert smokers to e-cigarettes". Daily Nebraskan.
- ^ Neil Nisperos (4 September 2014). "Vaping convention coming to Ontario Convention Center Friday". Inland Valley Daily Bulletin.
- ^ Mary Plass (29 January 2014). "The Cloud Chasers". Vape News Magazine.
- ^ a b c Sean Cooper (23 May 2014). "What you need to know about vaporizers". Engadget.
- ^ Dominique Mosbergen (5 August 2014). "This Man Is An Athlete In The Sport Of 'Cloud Chasing'". The Huffington Post.
- ^ Victoria Bekiempis (1 April 2015). "Veteran E-Cigarette Users Fret 'Cloud Chasers' Give Them a Bad Name". Newsweek.
- ^ Fallon, Claire (19 November 2014). "'Vape' Is Oxford Dictionaries' Word Of The Year". The Huffington Post.
- ^ Etter, J. F.; Bullen, C.; Flouris, A. D.; Laugesen, M.; Eissenberg, T. (May 2011). "Electronic nicotine delivery systems: a research agenda". Tobacco control. 20 (3): 243–8. PMC 3215262 . PMID 21415064. doi:10.1136/tc.2010.042168.
- ^ a b Beard, Emma; Shahab, Lion; Cummings, Damian M.; Michie, Susan; West, Robert (2016). "New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?". CNS Drugs. ISSN 1172-7047. PMID 27421270. doi:10.1007/s40263-016-0362-3.
- ^ Barnaby Page (5 March 2015). "World's law-makers favour basing e-cig rules on tobacco". ECigIntelligence. Tamarind Media Limited.
- ^ Lempert, Lauren K; Grana, Rachel; Glantz, Stanton A (2016). "The importance of product definitions in US e-cigarette laws and regulations". Tobacco Control. 25 (e1): e44–e51. ISSN 0964-4563. PMC 4466213 . PMID 25512432. doi:10.1136/tobaccocontrol-2014-051913.
- ^ a b "U.S. Department of Transportation Explicitly Bans the Use of Electronic Cigarettes on Commercial Flights". March 2, 2016. Retrieved 3 March 2016.
- ^ Sienuic, Kat (29 September 2014). "Public health officers tackle hazy issue of e-cigarettes". The Globe and Mail.
- ^ Kadowaki, Joy; Vuolo, Mike; Kelly, Brian C. (2015). "A review of the current geographic distribution of and debate surrounding electronic cigarette clean air regulations in the United States". Health & Place. 31: 75–82. ISSN 1353-8292. PMC 4305454 . PMID 25463920. doi:10.1016/j.healthplace.2014.11.003.
- ^ "E-cigarettes to be stubbed out for under-18s". BBC News. 26 January 2014.
- ^ a b c "The Facts on the FDA's New Tobacco Rule". US Department of Health and Human Services. US Food and Drug Administration. 7 August 2016.
- ^ "Retailer Overview of FDA Regulations for Selling Tobacco Products". US Department of Health and Human Services. US Food and Drug Administration. 8 August 2016.
- ^ Eric Lipton (2 September 2016). "A Lobbyist Wrote the Bill. Will the Tobacco Industry Win Its E-Cigarette Fight?". The New York Times.
- ^ Gray, Eliza (27 February 2014). "Europe Sets New Rules for E-Cigs While the U.S. Drags Its Feet". Time (magazine).
- ^ "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. US Food and Drug Administration. 79 (80): 23142–23207. 25 April 2014.
- ^ Sabrina Tavernise (24 April 2014). "F.D.A. Will Propose New Regulations for E-Cigarettes". The New York Times.
- ^ National Conference of State Legislatures (5 May 2016). "Alternative Nicotine Products Electronic Cigarettes". National Conference of State Legislatures.
- ^ Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (01): 060–065. ISSN 0094-6176. PMID 24343348. doi:10.1055/s-0033-1363468.
- ^ Maloney, Erin K.; Cappella, Joseph N. (2015). "Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers?". Health Communication. 31: 1–10. ISSN 1041-0236. PMID 25758192. doi:10.1080/10410236.2014.993496.
E-Cigarette Forum 051817 UK
[Thorpe] Welcometo Beyond the Data.
Phoebe Thorpe, and herewith me today is Dr.
Brian King from CDC's Office onSmoking and Health.
Thank you for joining us Brian.
[King] Thanks somuch for having me.
It's a pleasure to be here.
[Thorpe] Our topictoday is E-cigarettes.
Can you tell us why they areconsidered a tobacco product? [King] Yes, so in the UnitedStates we regulate tobacco products through the US Foodand Drug Administration, and the way they describe atobacco product is any product that's made or derivedfrom tobacco.
And we know that the vastmajority of nicotine that's used in tobacco products,including e-cigarettes, is indeed derived from tobacco.
So since these productscontain nicotine, we consider them a tobaccoproduct in the United States.
[Thorpe] And E-cigarettesare little bit different than regular cigarettes.
Can you describe how they work? [King] Yeah, so E-cigarettes isshort for electronic cigarettes, but we know them by alot of different names.
And they can be calledthings like vapor products, hookah pens, vape pens, butthe bottom line is they're all really the same product.
And they work by containinga liquid that's heated which the user then inhales intotheir lungs, and it's important to note that this isn'ttechnically a vapor which is how peoplefrequently refer to.
It's actually an aerosol thatcontains small particles as well as various other ingredientsthat the user inhales, and so there's no combustion.
You're not burning anything, butthere is a heating of the liquid which turns into an aerosolwhich the user inhales.
And they can alsoexhale into the air as other bystandersare around them.
[Thorpe] And the aerosolis not just water vapor.
I mean, that's animportant part to understand because I get asked as aphysician about E-cigarettes, and the thing from the session that I found veryinteresting was the idea that were not reallycertain about the risks that flavorings addto E-cigarettes.
The one that was mentioned wasthe butter flavoring Diacetyl that has been associatedwith bronchiolitis obliterans or what's called popcorn lung,which is a deadly disease.
What more do we know aboutthe risks of E-cigarettes? [King] So our knowledgeabout what's contained in both the E-cigaretteliquid as well as the aerosol hascontinued to evolve over time that these products enteredthe United States marketplace in around 2007.
They didn't really start touptick in use until 2010, 2011.
But, since that time, we reallyincreased the amount of research into what these productscontain.
And what we can say isthat the aerosol admitted by these productsis not harmless.
We do know that the ingredients and the levels aresignificantly less dangerous than conventional cigarettes,but that doesn't mean that they're completelyrisk-free.
And so, some of theingredients we found in the E-cigaretteaerosol are things like ultrafine particulatethat can be inhaled very deep into the lungs, and alsoheavy metals that are found in the filaments of the deviceand are omitted in the aerosol, as well as, things likevolatile organic compounds.
But one of the most commoningredients is nicotine, and we know that nicotineis highly addictive.
But there's alsoevidence indicating that it can harm thedeveloping adolescent brain which really makes itimportant for youth to avoid these devices.
In addition to some of theseother harmful ingredients, we also know the flavorings.
And so, Diacetyl is justone, but there are a variety of different flavoringsthat are used that, although they may be safe toingest in things like food, we don't know what the risks are for inhaling thesedevices into the lungs.
You know, your gut can handlea lot more than your lungs, and that's reallyimportant when we look at the ingredientsin these products.
And finally, it's alsoimportant to remember that people are using a lotof things in E-cigarettes, and that includes otherpsychoactive substances like marijuana andTHC and others.
And so, when we are talkingabout youth in particular, the use of both the nicotinecontaining varieties as well as other varietiesfor other types of drugs are really apublic health concern.
But we have had somerecent good news about the youth meaningmiddle school and high school useof E-cigarettes.
Can you tell me about that? [King] Yes.
It's really a commendablepublic health accomplishment.
We started assessing E-cigaretteuse among youth in this country in 2011, and through 2015,we saw exponential increases in the use of this product.
And 2016 was the first time that we actually saw declineamong youth in this country, and that was really a resultof the coordinated efforts to not only educate thepublic about the harms of youth E-cigarette use but also implementingcommon sense strategies to not only prevent youth accessbut also to protect people from the aerosol andpublic environments and various other campaigns to educate peopleabout these products.
But, on balance, the badnews is that we still have over 2 million youth thatare using E-cigarettes, and they're now the mostcommonly used tobacco products used among US youth.
So we made great progress,but we really need to continue that momentum toreduce all forms of tobacco productuse among youth.
[Thorpe] So it's going down, butnot as lot much as we'd like.
So what's driving the use ofthe E-cigarettes in teens? [King] So there's avariety of factors that we believe are contributingto these increased rates of use among youth thatwe saw through 2015.
One of the most notable is theadvertising for these products.
We know that many of the themesand tactics that have been used to advertise conventionalcigarettes are frequently used for E-cigarettes.
And we also know thatthere's some media of for which conventional cigaretteadvertising is banned that is allowed forE-cigarettes.
Things like television.
And so, there's reallya prominent advertising of these products, and we know that it's reachingkids in particular.
About 18 million US youthreported being exposed to E-cigarette ads in 2014.
Another factor isflavorings, and we know, from the existing science, that flavorings can beparticularly appealing in terms of enticing youth and youngadults to use tobacco products.
And a variety of E-cigarettesare flavored, and we know, from the existing data, thatabout two thirds of youth who use these cigarettes reportusing flavored varieties, and flavors are the mostcommonly cited reason for why youth startedusing these products.
And so, in the end, wereally have a situation where you know the advertisingis bringing the horse to water.
The flavorings aregetting them to drink, and then the nicotine is keepingthem coming back for more.
And so, it's kind of aperfect storm in terms of the youth rates of this use.
But the good news is, we knowwhat works to prevent that.
And if we implement those commonsense public health strategies, we can continue to seethe declines that we saw within the past yearamong our nation's youth.
[Thorpe] And the realconcern is about nicotine and the teenage brain.
Can you just briefly tell mea little bit more about that? [King] Yeah.
So nicotine is found in thevast majority of E-cigarettes that are sold on the U.
marketand, you know, nicotine we use in things like nicotinereplacement therapy among adults.
And it can be, youknow, an effective drug to help people quitconventional cigarette smoking.
But it's important to note thatthose are in very measured doses and weans the individual off of conventional cigarettesover time.
But nicotine is notnecessarily risk-free.
Particularly forvulnerable populations.
We know that nicotineis highly addictive, but there's also a growingbody of scientific evidence that was outlined in a recentSurgeon General's Report noting that nicotine exposure can harmthe developing adolescent brain.
And we know that thebrain continues to develop into young adulthood upthrough 25 or 26, and so, there's really implicationsfor not only youth use of these products butalso young adult use of any nicotine containingproduct.
And another thing to remember with nicotine is it'salso been shown to result in adverse health outcomesamong pregnant women in particularly fetal toxicity.
So there's also implications about pregnant womenusing any form of nicotine containing product,and so, it's really important for them to talk with theirphysician before they use any type of nicotine containingproduct including E-cigarettes.
[Thorpe] So is there a placethat physicians could go to learn a little bitmore about these parts with the E-cigarettesand the nicotine? [King] So there's many resourcesthat have been developed over the past fewyears, particularly as the sciences begun to grow.
And we have, you know,more concrete evidence about what works effectivelyto help warn people about these products and alsoprovide them scientific-based information to makeinformed decisions.
And in 2016, the U.
SurgeonGeneral released a landmark report on E-cigarette useamong youth and young adults.
And as part of therelease of that report, there were severalmaterials including resources and provider cards to helphealth professionals really communicate to both childrenand adults about these products.
And so, in the context of youth, it really enforces theimportance of warning them about the dangersof these products.
Particularly with regardto the nicotine content.
And among adults, it's amore nuanced conversation about knowing that we dohave FDA approved medications to help people quit, and thoseshould really be the first line of defense to help you quit.
And if that doesn't work, youcan consider E-cigarettes, but in consultation withyour healthcare provider.
And right now, based onthe evidence we have, there is no conclusive evidencethat E-cigarettes are effective for long-term cessation, andso, it's really important to use those resources thatwe know are most effective to help you quitand in coordination with your healthcare provider.
[Thorpe] And then foryouth, where if parents or other adults wanted to knowmore about how they could talk to teens and young adults aboutthe risks of E-cigarettes, where would they find someinformation about that? [King] So as part of the releaseof the Surgeon General's Report, there's an excellent interactivewebsite that was coordinated with the release of that report, and it isE-cigarettes.
And it has a varietyof information on both the reportitself as well as a public service announcementas well as informational cards for both parents andclinicians to educate our youth and young adults in particularabout the dangers and risks of using these products.
[Thorpe] That sounds like anexcellent place for our viewers to go and see whatthey can find out.
Thank you very muchfor joining us.
[King] Thank you verymuch for having me.
[Thorpe] And thankyou for joining us.
See you next monthon Beyond the Data.