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-Liquid
Nicole Aune: I think we're going to go ahead and get started.
So, hello everybody.
Thank you all so much for coming out today, and we may have a few more trickling in, but, um, I just wanted to thank you guys for just taking time out of your evening to come here.
My name is Nicole Aune.
I am a program manager with the Montana Tobacco Use Prevention Program.
I oversee the policy and cessation work.
Um, and we're really here today because there is a new product on the market and it's really captured the attention of our youth and it is the most commonly used tobacco product among our high school students in Montana, and that's E-cigarettes.
So there's a lot of mis-information out there about E-cigarettes and, and it's a confusing thing.
Um, there's a lot of questions and, depending on who you talk to, you're getting different answers.
So, we're here today, um, to hopefully answer those questions for you and give you all the facts and information for you to go out and then talk to your kids and other young people about, about the facts and share this information with others.
We're going to go into what we're going to cover today, so we have some awesome speakers and we're going to be covering what E-cigarettes are.
Um, looking at how many, how many kids in Montana are actually using them.
The why are kids actually using these products.
Why, why are they so into them, and the health dangers that, the health risks associated with E-cigarettes.
Um, and we're also going to talk about how the tobacco industry targets kids with these products, and then mention what you can do.
And we have an excellent line-up of speakers.
Kris Minard: All right.
So Nicole mentioned this is mostly for adults right now, although it's very important kids know about this too.
But this particular um, presentation is, is geared for you.
We'll talk about Montana youth trends and um, let you know more about what electronic cigarettes are, their appeal to youth and then what's actually in the E Juice.
Every time we give a presentation we have to remind people we're talking about tobacco products and tobacco is still the leading cause of preventable death in the United States, killing almost a half a million people every year, which is the same as three fully-loaded 747's crashing every day, with no survivors.
So, if something like that happened, I think people would really take up, take notice and we, we need to remember we still have a lot of, we've done some great work on tobacco, but we have a long way to go.
So, as far as Montana youth trends go, we have great data, stretching back into the early 90's from the Montana Youth Risk Behavior Survey.
Our high school students are asked every other year, um, about their risky behaviors and how much they participate in them.
And, as you can see, these are the kids who say they have every tried smoking cigarettes, even one or two puffs.
We've got a nice trend down from the 90's.
We're at about 39% of our high school students who say they've even tried using tobacco.
These are the students we call current users.
The CDC says if a student responds that they've smoked a cigarette in the last 30 days, then we're going to call them current users.
A lot of people might think that Montana has more smokers on average than the rest of the country, but our, our students have really much um, kept up with the national average all through these last 20+ years.
However, you can see in 2015, 13% of our high school students say they smoked cigarettes and only 11% um, in the nation said they are, so we are above the national average there.
Then we've got these guys, these fruity-flavored, cheap, inexpensive um, cigars, cigarillos, that are kids have, have noticed and, and started using.
We are well above the national average at about 13% compared to 10.
Still a little bit of a decline, but nothing like, you know, it hasn't been as high as the cigarette use, but it's right at 12.
6%, which is pretty, I mean, they're both basically 13%.
Here's where we stand out.
Our smokeless tobacco.
Still 12% of our high school students say they use smokeless, um, snoose, chew, and ah, compared to the national average of 7.
3%, so our high school boys are huge users.
One in five of our high school boys report using smokeless tobacco, fourth highest prevalence of use in the country.
Our girls also have the fourth highest prevalence of use, but it's at a much lower um, prevalence, 4.
So here are all three of the traditional tobacco products.
You can see they're all at about the same level in 2015.
So now we have these guys, these electronic cigarettes.
Well, they all basically deliver nicotine.
There are a very few that don't have some of the E Juice, has zero nicotine in it, but by far most deliver nicotine and they almost all have lithium.
Well, I don't know any that don't have a lithium battery.
They look like lots of different things.
Some look like cigarettes.
Some look like marking pens.
The one on the right, I say kind of looks like a mini lunar lander, and they're just constantly changing.
These things are evolving practically daily.
We also have um, electronic cigarettes we call mods that, these are the products that people typically drip the E-Juice into and they create the great big huge, we say vapor and vaping, but it's really not a vapor, it's an aerosol.
There are tiny particles of metals and, and it's actually an aerosol.
You can see someone even ingeniously made a E-cigarette out of a Coke can.
But they all basically have a mouth piece and someplace to put the E-Juice, whether it's already contained and in a cartomizer or if it's a tank that you have to fill, or if it's an atomizer that you drip onto a cotton swab with E-Juice.
Then they have the heating element, which is the atomizer which heats up, so there's no combustion as with cigarettes.
There's nothing burning.
It just heats up it and creates this, this aerosol in the lithium battery.
Here's a video that NJOY has for anybody to watch on the Internet about how to vape.
(Video) This is NJOY's vape pen.
You picked it up off the shelf or got it in the mail, but it might be intimidating.
We're here to help.
If you're ready to vape watch on.
Part One: Assembling the Vape Pen.
First, you're going to need a bottle of E Liquid, like this.
You can buy NJOY E Liquid wherever you purchased your vape pen.
Next, make sure the battery is detached from the tank.
Don't try to fill the tank with E Liquid when it's attached to the battery.
Unscrew the mouthpiece from the tank.
Open your E Liquid.
NJOY E Liquids are in bottles with child resistant caps.
So to open it, you'll need to push down on the cap as you turn it.
You don't want E Liquid in the center tube.
So when you fill your tank, tilt it and drip the E Liquid down the side.
You can check the milliliter amount by the markings on the side of the tank.
Remember to keep E Liquid away from your skin.
If you happen to get some E Liquid on your hands, make sure to wash them immediately.
We also recommend that you have different tanks for different flavors of E Liquid and that you discard any tank after about two weeks of regular use, depending on how you vape.
Changing your tank will assure that your vapor always tastes great.
Once you fill the tank, screw the mouthpiece back on.
Make sure the mouthpiece is on tight, then screw the tank on to the battery piece.
Now you're ready to vape.
Part Two: How to Vape.
Your pen comes activated right out of the box.
To deactivate your vape or to reactivate it, quickly press the button five times in a row like this.
The LED light flashes five times when your vape pen changes state.
When your vape is activated, put your lips to the mouthpiece.
Inhale as you press the button, and just like that you're vaping.
Part Three: Charging.
The LED light will flash 10 times during use when you need to charge your vape pen.
To charge, simply unscrew the battery from the tank and into the USB charger.
To preserve the battery, don't charge it in a place that's too hot or too cold.
You'll know it's charged when the LED light goes off.
Kris Minard: Anything, time for a little audience interaction.
Anything kind of catch you off guard on, on that one? Anything kind of noticeable? __: Wash your hands.
KM: (Laughter) If you get any of this E Juice on your hands, wash them immediately.
It's okay to inhale it into your lungs, but by golly, if you get it on your hands, wash it off.
Well, nicotine absorbs through everything and um, Dr.
Shepard will talk to us more about the effects of nicotine.
All right, um, gimmicks, there are lots of gimmicks.
The industry, the tobacco industry has had gimmicks for years.
Coupons and products, give aways and things like this, and make no mistake, the tobacco industry is invested in electronic cigarettes.
Yes, there are mom and pop vape shops, but RJ Reynolds, Phillip Morris, Lorillard are all into, into these products.
blu is one that you may have seen ads for on T.
These are what they call the starter kits, and this particular thing costs about $75.
00 a couple of years ago.
I don't know what they cost now.
I would think that the price has gone down.
They look like a cigarette.
They charge right in these cases and their gimmick is each case has a little wireless transistor radio in it, a radio wave, that if you turn this on, this is, this it'll, this is what it will do.
If you're within 50 feet of another person who has one of these.
So they want you to know who's around, who can you go buddy up with, turn it into a social experience again, and um, find somebody, you know, there's somebody around who's using this.
Let's find out who they are.
They also do this if they're within 50 feet of a place that sells the refill cartridges.
So, that's their, that's their gimmick on, on these.
The I Phone case.
It's all set up.
It's got it's own battery and ah, I think this is for ah, I'm not sure, I think it was an I Phone 5, but it's got a mouthpiece.
You can screw your own mouthpiece into the top and, and vape away.
They want to appeal to the environmentally conscious folks.
Our landfills are being filled by these batteries, these empty cartridges.
You know, a lot of really bad toxins and, and pollutants.
So they say, send us your old products and for every 50 old cartridges or old lithium batteries, whatever you send us, we'll give you so many points to buy our products.
So it never ends.
Ah, this woman is going to show you how to use blu and a couple of the, of the other products.
(Video) Um, and this is a blu disposable.
We're going to pull the little seal off of here.
Pull the little rubber cap off and puff.
That's it, nice and simple.
Now the blu starter kit has um, two batteries, five cartomizers and a charger.
These are re-changeable.
Um, this same concept.
Screw the closed cartomizer.
Everything you need is mixed up in here already.
Screw it on and again puff.
Nice and simple.
Another company we carry Smoke Stick, same, same principle.
We have a disposable.
You have an E, the starter kit.
Again, screw it on.
That, as you can tell, is a little bit more vapor than the blu gave me.
Kris Minard: So she had a lot of quick hits of nicotine right there and you can tell she kind of liked that Smoke Stick brand, because it created a little bit more, more vapor.
Um, we'll talk a little bit about these mods.
Um, the people build these themselves, and you can learn all about them on the Internet.
There are people who have their own YouTube channels that show you how to create these things, and they take great pride in creating the coils, and how many, how many turns and twists you have in them, um, relative to how many ohms it's going to produce, and you want to heat it up just.
It's all supposed to be red when it heats up and you put the cotton wick between it and that's what you pour the E Juice onto.
This is an RDA, re-build able dripping atomizer, and this is a mod that has fully computerized.
This whole set costs about $140.
00 here locally.
The battery is another $80.
I did not purchase it, and you can set it to all sorts of different levels to decide how hot you want it to get, how much vapor your, how much aerosol you want to create, and, um, all these little buttons help you.
We'll just pass this stuff around so you all can, can look at it.
There's a great tobacco prevention specialist out, out east who told me, she likes to put things in pencil kits and pass them around and see if people can figure out what's really a pencil and a marker, and what's really a, an E-cigarette, and I said that is a great idea.
So I copied her and it's pretty impressive.
Take a look through this pencil kit, see if you can pick out the E-cigarettes.
This is the fellow who's got one of the YouTube stations or channels and he's got over four million views on, they call them clouds making this big huge cloud with a, with a mod.
So now let's talk about teen vaping and why, why our kids are so, so interested in them.
The 2015 Youth Risk Behavior for their first time asked the question, "Have you ever tried an electronic cigarette and in the last 30 days how many times have you used one?" And you can see by the description they couldn't just say an E-cigarette, they had to define it so that the kids would know what they're talking about, because they're called so many different things.
I mean now you might just hear the word vapes, um, but the responses in Montana really caught us off guard and we were alarmed.
Fifty-one percent of our high school students said they tried them compared to 45% in the rest of the country, which is also huge.
This is what the percentage of people, the high school students who have tried them, broken down by male and female, so not a big difference between the two.
Boys typically have riskier behavior than girls, but you can see it increases with grade level.
A, every year you have more kids using these products.
And granted by 12th grade, some people are 18.
There's no question.
It would not be illegal for them.
Another reason, as Nicole has pointed out, why it would be great to have 21 be the age for using tobacco.
There would be no question.
There are no 21 year olds in high school.
Not in Montana.
They don't fund them.
And this is a question of whether they're current users.
Have they used one in the last 30 days.
So 30% of our high school students said they were current users.
Almost one in three.
And here's that breakdown.
Same, same thing.
Pretty close to the same, but still more boys, and again the same kind of transition from nine through twelfth grade, increasing each, each grade level.
So here are the three traditional tobacco products and then the E-cigarettes in green.
It's kind of a visual deal that boy, twice as many kids, more than twice as many kids are using this product and are smoking.
So anybody who tells you, oh it's just the kids who are smokers who are using this product, that's not true, and this shows you that.
Here's a breakdown by groups.
Um, the state averages of cigarette smokers and vapers, um, on the left and then some of our middle schools actually take the very same Youth Risk Behavior Survey, so those that do have showed us that, wow, twice as many middle school students are vaping as are smoking.
NAR, our Native Americans on a reservation, so that is the only group who are smoking cigarettes is still higher than vaping, but, but not much.
NAU, our Native American's in an urban setting, big difference.
NPA, Non-Public Accredited schools.
A lot of your private religious schools, um, like Central in Butte, Central in Billings.
ALT, those are alternative schools.
That's where our risk takers are and we know that there are huge issues there, and we've got a few projects that we're working on, but boy we, we need to do a lot of work there.
SWD, our Students With Disabilities.
So they're attracting all, all users.
Yale had a great study a few years ago, where they asked 5,400 young people who did vape, what's cool about it? What do they think makes them cool? They were not surprised by the answer, the flavors.
We've all seen and heard, and you're going to hear more from Sara tonight about the flavors, but they were taken back by the fact that kids said we can do vape tricks with them.
So vape tricks.
We're going to show issue, show you a few videos from on-line about what they're doing with these products.
(Video) What's up guys.
We're here at Flawless Vape Shop in Anaheim Hills, California for the 8th Trick Qualified __________________________.
(Music) Ricky was sad.
He just won the 8th Trick Qualifier for the BC Cog Championship.
How do you feel? I'm stoked Still a little nervous? Yeah.
(Laughter) What did you do to prepare for this competition? I vape every day because I work in a vape shop, so.
What vape shop do you work at? Vaper Hub.
Would you like to thank any of your sponsors today? Of course.
Got to thank LindaLace, Good Vibes, Vape Socks, Native Wakes of course, you know.
Good Vibes is my sponsor too.
Good Vibes is awesome.
(Laughter) So before you go, ah, do a signature trick for us.
Kris Minard: Um, anything catch you off guard? Anything kind of impressed you with that? __: The sponsorships.
They have sponsors.
It's like NASCAR and these are young kids.
I mean, he, he was probably 18 or 20.
To me he looked like he was 16 or so, but he said he vaped every day.
I mean, what is he doing to his lungs.
You have to practice a lot to, ah, when you see the next ones you'll, you'll be impressed.
(Video) Kris Minard: I just wanted to show you that girls are doing this as we know.
How'd you like to be the little brother pushed through the aerosol there? The last one is the, oh __: ________________ Is there an odor to it? Kris Minard: There is a slight odor to it, but that's a really good question because someone asked last night, are they using marijuana in these things? And they are, they are.
__: Something like for the feel um, my parents said on the clothing Kris Minard: Oh, can't smell the clothing, right.
Definitely not like tobacco.
There, there is an odor, but the thing about marijuana, is if they are using marijuana, there is no distinctive marijuana odor with these, so someone could be vaping pot right in front of you, um, and you wouldn't know it.
So, but, but, they say there is not much of an odor with these, but I have smelled bubble gum.
I have smelled some of the flavors, when we have done some experiments with, with bottles.
Um, oh yeah, this, this guy, I think this is the one that use.
Oh, you'll want to go back and then that one is a video.
This guy is a real professional.
(Video) Kris Minard: So, you can see.
There's a challenge to them.
There's a competition.
Um, this guy won $10,000, making as big of a cloud as he could possibly could.
So, there are competitions all around the country.
I've not heard of any in Montana, but you know how we are, a little bit behind other states sometimes on things.
We'll hope, we'll hope that we don't get any here, but there's money, there's challenge and kids get good at it.
They take pride in it and who knows what they're doing to their lungs.
So, we often hear well it's just a harmless water vaper.
Well, it's really not.
In fact, there isn't water in these things.
The three main ingredients are propylene glycol, which is something that we use in the theatre in fog machines, and it's generally recognized as safe as an edible, um, chemical.
But that doesn't mean that it's safe for our, for our lungs.
You know, eating something and inhaling something are totally different.
I often say it's okay to eat a peanut, but if you inhale a peanut, you're in trouble.
The flavorings are another thing that's typically in, in the E Juice and nicotine.
Um, and these have not been regulated by the FDA, so some have been found to contain all sorts of carcinogens as well as other toxic chemicals.
Um, the carcinogens on the left, Acetaldehyde, Benzene, Formaldehyde is created as the E-cigarette heats up and, and, so it's actually the heating of the E Juice that creates the Formaldehyde.
Nickel, Nitrosamines, um, and then other toxins, other irritants.
A Diacetyl is an ingredient that has added to the flavorings to help make the flavorings work better.
And you may have heard of popcorn lung.
People who were working in microwave popcorn factories were getting this irreversible lung disease, and they finally figured out it was from the Diacetyl.
Well, Diacetyl is in a lot of E Juice.
I have, I always say if you have to dress like this to work with this product and develop this product in a hazemat suit, then why on earth would anybody want to be putting it into their lungs? Congress did pass a Child Nicotine Prevention Act because a teaspoon can kill a child.
In fact, there was a young toddler who died just before Christmas a couple of years ago.
He got into his parent's E Juice, so, um, now they do have to have child-resistant tops.
Poison Control Center calls have grown exponentially.
In 2014 they increased from one a month to 215 a month for exposure to, to nicotine.
These, this is a little bit deceiving because the 2015 and 2016 data isn't complete on this.
I've been looking for better, updated charts, but, um, it's been a major increase for Poison Center Control calls.
And then you also heard about these exploding lithium batteries.
Um, the industry will tell you, oh it's user error.
You know, it's always user error, but I read an article about a man who opened a package and it blew up.
You know, he wasn't even using them.
We have a, had a young student in Missoula who was vaping and ended up losing four teeth and I really, I mean that was a very traumatic experience.
He had a really hard time getting back to school.
I mean, you can imagine.
It caused a fire on the couch he was sitting on.
So, not good.
This is an example.
Watch the guy standing at the counter on the right.
(Video) Kris Minard: Huge vap, you know plume of, of aerosol and he had to take off his pants and you, you saw the burns ahead of time.
So that's the end of my presentation and we have an, um, question and answer session.
So if you have some questions, we'll do that at, at the very end.
But thanks a lot for coming and thanks for listening, and if I can help you in any way, let me know.
Kathy Rogers: Research suggests that compared to adults, teens value reward more than consequence.
And we kind of all know that, but that is really an integral part of brain development in adolescents.
It is part of what gets them to grow up and leave home.
To go on the adventure of leaving the security of a household where somebody feeds them and clothes them, and takes care of their needs, and goes out to where they're going to have to figure it out.
And so it's, it's an important part of development, but it is also is what makes them take the risks that they do.
Brain development takes a long time, sort of from age 12 to age 25.
And so at 18 and 19, when these kids legally can do a lot of things, they still don't have a very mature brain.
They think they do and if you think back, you thought you did.
And then you got a little older and you realized your parents were not nearly as stupid as you thought they were.
And we hear that said all the time, but it really is true and there's no way to explain it as we grow up.
You can say it to your kids and they nod and think you're full of it, but it's really the truth.
So it, brain maturation moves in really slow waves.
It starts at the base of your brain and kind of moves forward in very basic functions, so it starts with your vision, what you see, and then movement, and then fundamentally how you process things.
The more complicated executive functions.
So this front part of your brain, which is the last part that really puts together, if I jump off of this very tall building, I may break my legs.
And the other part of it says, yeah, but won't it be really cool if I don't.
That part takes a long time to come together, and so there's all these different parts of the brain that you're going to hear talked about as, as more of the issues of brain development go on.
You're going to hear them talk about your hippocampus, which is part of your memory.
The frontal areas set goals.
They weigh agendas and risk and that frontal part is really important.
Um, head injuries, a lot of frontal injuries impact how well we do our executive functions and this is sort of a side comment, but the whole business of concussion relates to what happens when you're constantly impacting that frontal area, which becomes your consequence setting goals, agenda, risk assessment area.
Um, so ultimately development allows us to balance our impulse and desire and our self interest and put that together with ethics and rules, and to put all of that together.
But it takes time and you can have a kid who will say, I know I shouldn't, but they still will until they get on the other side of that fence.
If you think of teen decision making like an equation, where consequences aren't given the weight they should be, rewards weigh more heavily than they should, and where being friends throws the equation off any more.
So that plastic part of your brain really looks at thrill seeking, risk taking, and I don't have a graph to show you, but when you look at higher risk and lower risk and then age, the ones who enjoy it the most are 16 to 17 year olds.
They just, that high risk is like a really good reward, and it's interesting because at 18 and 21 it starts to drop, but it doesn't get down to a level less than when you're 10 years old till you're 26 years old.
So, there's a long time where that is all really important.
Most long-term drug use, alcohol, tobacco, nicotine, starts in adolescence.
And we all recognize that.
Teens do know they're mortal.
They can estimate risk, often over-estimating risk.
They simply value the reward so much more heavily and the more risk they take, if the reward is good, is perceived as a better payout.
And what helps them add to the risk? Doing something with their friends.
So when you look at kids who are learning to drive, there's lots of good valid studies that show.
If you put a kid in a car with an adult, their parent, they will drive beautifully.
They take Driver's Ed, they do really well, and as long as they are in the car with the adult, they're great.
You put one person in the car their age and all of a sudden they run through the red light.
You put two or three kids in the car with them and suddenly it's what can we do? Where can we race? Why? Because there's this huge reward of doing these things, taking these risks with their friends.
So, when you're looking at kids related to cigarette smoking, vaping, it's the same thing.
And so one of the key questions I always ask kids when I'm interviewing them, is do any of your friends vape? Because if you ask them directly, you may or may not get a straight answer, but they don't have any problem telling you if their friends do.
And that's a really good way to kind of come in through the back door when you want to find out what's going on.
Because if their friends are vaping, you can bet that for them it's a greater opportunity, even if they think they're only going to do it once.
So, what their friends do does make a really big difference.
Now, this time of taking all these risks is important.
They need to do this.
It doesn't make them obnoxious, although sometimes it feels like it does when you're the parent.
Um, but that's partly again what gets them to learn how to be independent and on their own.
So adolescence brings a peak in brain sensitivity to dopamine, which is a neurotransmitter, that kind of primes you for reward.
And it fires off the reward circuits.
So anything that improves and effects dopamine is something that they like, and nicotine will effect that as does marijuana and so these sort of spark that area and kids go, oh that felt good.
And feeling good is something you want to do.
Believe it or not, texting fires off that part of your brain, which is why those ridiculous texts of what'ch doing.
Where're you going to be? Not sure.
And yet they're just addicted to it.
They literally fire off that little bit of dopamine over and over again, which is a little pleasure center.
Um, for those of you are old enough, if you remember what it was like to get a letter in the mail and you would wait for the mailman to come.
It's the same thing.
It just didn't happen every five seconds.
So that's part of the difficulty and again, anything that will allow them to get there.
Teen brains, neuro networks are being pruned, and so they're still in that developmental phase.
And it's really interesting, teens prefer teens.
So the things you say do make a difference, but they search out their friends and that's, those people are their investment in the future.
They're not going to spend their life living with you.
You guys are their mentors/directors, but they know you and you're not exciting any more.
Their friends are exciting and that's where they want to be.
So again, who they spend time with and we're back to, what makes me feel good? What's exciting? Um, you guys have the statistics and will probably go over them, so I'm not going to take about the percentages of kids who are using E-cigarettes.
But what I will tell you is, for child, for kids, it's not a reduction of harm.
They use E-cigarettes and they talk about it for adults as a reduction of harm, getting them off of cigarettes.
It doesn't do that for kids.
It becomes the gateway.
It addicts them to nicotine, and we know from both human studies and mouse models, that at the developmental point in your brain that you are when you're a teen, your brain is more plastic and nicodine, nicotine is far more addicting.
We don't know why.
We just know it is.
And it's that developmental phase.
We also know that the various products like nicotine and marijuana at that stage long term will affect brain function.
So when you were talking about the different products that are in there.
So nicotine poisoning, what does it look like? Vomiting, sweating, dizziness, increased heart rate, lethargy, seizures, breathing difficulty, um, it's a neural stimulant at low doses, but at high doses it's a depressant, and it really gets them into trouble.
A couple of things that you need to know and that parents should share with each other; anti smoking actions by parents are a strong predictor of non-smoking in teens.
Anti tobacco opinions, anti vaping opinions and discussions with parents are factors that protect kids against tobacco, even if a parents smokes.
So even if you're a parent who does smoke, the very fact that you say no, makes a huge difference.
The bottom line is, is that you want to make the risk and the reward enough like the reward for not doing this, greater than the reward for doing it, and because nicotine's so addicting, you've got to find ways to sort of them, it's like the toddler thing.
You have to distract them over here.
You keep them busy with other things that are rewarding and fun for them whether it's school or trips with friends that you get to help plan and organize.
But it's pretty basic and it's pretty simple and I can go through all of the neurochemistry and, and all of the brain development doesn't mean anything.
The bottom line is, they like what feels good and what you have to do is find things that make them feel better and make it new and exciting and just sort of distract them until their brain gets to that point and then you also make it clear that this isn't something that you want them to do.
But that's not what you harp on all the time.
You just do the distraction.
That's my line.
Robert Shepard: Um, all right.
I entitled this Nicotine, Safe or Dangerous because I was up at the Legislature trying to get them to increase the tobacco tax, the bill supported by the Governor and Cancer Society and Heart Association, to increase the tobacco tax and ah, they were going to include E-cigarettes on that increase, and actually I was flabbergasted, is the best way to put it, at some of the claims that were made by the E-cigarette proponents about the safety of E-cigarettes and the safety of nicotine.
So, since nicotine is the predominant ingredient in all of the E-cigarette liquids that are set out, I wanted to talk a little bit tonight about nicotine.
Now, before we get to there, we can talk about tobacco and several different oranis, several different kind of categories.
Obviously, there's combustible tobacco, cigarettes, cigars, pipes, and those, those things have a completely different of chemistry.
After all, they're, they're burning, they're burning at a very low temperature really, so they create all kinds of chemicals that get into the air, and that creates all the second-hand smoke and other stuff which is the primary motivation for second-hand smoke laws.
Ah, but we're not going to really talk about combustible tobacco tonight.
You've got your various forms of spit tobacco.
I like to refer to it as spit tobacco to make sure that it's overly glamorized.
Um, but in any case, you've got the various forms of spit tobacco and they also have their own set of chemicals, but they're not heated.
They have chemicals that also that occur a lot during the curing process from the way the tobacco industry cures it, which creates a lot of extra stuff in the, in the leaf beyond just the tobacco plant.
And then lastly we have the E-cigarettes which you've heard about it, and they're not really combustible, but they're not exactly like ah, non-combustible chewing tobacco products because they are heated, and that also has a potential to create different chemicals.
Um, so, and I want to focus a little bit on nicotine now because, 90, somewhere around 97, 99% of all E-cigarette capsules and liquids that are sold are sold with nicotine in them.
So they talk about all the other stuff that goes on, but it really has to do with the nicotine.
So, is nicotine safe? Is it beneficial? Is it addictive? So let's kind of explore some of that.
First of all, there, the way the body works is most of the cells in our body have little tiny receptors on them.
You can consider the receptive would be a lock.
A molecule, a chemical will come by and insert itself into that lock and that creates, causes the cell to do something.
That's the way hormones work, whether they're thyroid hormones or testosterone or estrogen or any of the other, you know, cortisone, any of the other, ah, hormones around the body all work by attaching to a receptor on a cell.
And each cell will have tens of thousands of receptors on it.
It's hard to believe something so small can have that many receptors and there will be dozens of different kinds of receptors on every cell.
Some of these receptors then in the body are triggered by nicotine.
That's how nicotine does what it does.
So nicotine will glom on to, you know, insert itself as a key into that lock and then tell the cell to do something.
And they're really high in concentration in the brain, which should come as no surprise.
Secondly, there are a lot in the lungs and there's, one important thing is that there are an awful lot in the lining of the arteries, what we call the endothelium.
That's a lining of the arteries, incredibly important for the arteries being able to dilate and contract, and also important because when the lining gets torn or injured, cholesterol then leaks into the wall of the artery and that begins the plaque formation, ah, of heart disease.
And nicotine has profound impacts on that.
So there are impacts on the way the cell functions.
If you're looking at an embryo that's developing, these receptors will trigger development in different ways and consequently their impacts on the way the body develops as a result of that.
Ah, and this particularly in the brain impairs the development of neurons.
So as we are adding neurons as the fetus is growing it's brain, it's going to end up with fewer neurons in the brain because of nicotine exposure during pregnancy.
Now, how do we know all this? Well, there are lots of different ways that we know this.
First of all, there's studies of animals that we can, we particularly use a lot of rats and mice in these kinds of studies.
They're small, they grow quickly and we can study them a lot faster.
We also use primates, various kinds of monkeys and, and stuff in that.
Also we can know because we can look at systems in humans that are really vulnerable.
Systems like in pregnancy, where we have a growing, the fetus and the, that system is very very vulnerable to affects, so we can look for these sorts of things, ah, in that area.
We can also just grow the cells in a lab in a cell culture and then expose them to these products and see what impact it has on individual cells.
And there are not just multiple studies, but we're talking about thousands of studies about the impact of nicotine studied through all these different systems.
Now, the nicotine system in the brain, the nicotine receptors in the brain, have impacts on memory, how well we think, how well we focus our attention, and also on emotional responses.
Now, some people think that in adults, I'm going to say that again, in adults, nicotine might slightly enhance our memory, our ability to think and our ability to focus.
There are no good human studies that prove that that's the case.
When I was up at the state they were talking about the study in Discover Magazine, I like Discover Magazine.
I read it cover to cover every month when it comes out, and there was this highly speculative article about the im, the positive impact nicotine might have on the adult brain.
And it says right in the center of the article, there are no studies that show that this is true.
And yet, this, this journalist was making this great case for how wonderful nicotine was going to be on our brains.
Well, it ain't true.
Well, at least it's not been proven true yet.
However, when we are talking about a developing brain, again we're talking about fetuses, infants, toddlers, and we're also talking about adolescents as we hit, hit that period of time when that judgment part of our brain between 15 and 25, when we develop judgment in our frontal cortex, that presence of nicotine changes the way the brain develops, and that's not a good thing.
So there are fewer nerve cells, some of the nerve cells are damaged.
There are fewer connections between the nerve cells and there's all kind of changes in the brain chemistry.
Nicotine is a very powerful stimulant of the dopamine system.
Dopamine is our pleasure reward system.
When you get dopamine you feel good.
There are all kinds of things that give us dopamine.
Nicotine is one of them.
So, what about the fetus? Well, nicotine crosses the placenta.
There are more nicotine receptors in a developing brain because the body uses those receptors to guide the development, but when you add a bunch of nicotine to that and over-stimulate those receptors, you end up with some brain cells dying and some brain cells getting malformed and the number of some brain cells not forming the connections to other brain cells that they're supposed to have.
We know in human studies we haven't really been able to check this because for obvious ethical reasons, you're not going to take 1,000 women and say you get to take the nicotine and take another 1,000 women and say you don't get to take any nicotine, and see what happens to the baby.
Nobody is going to do a study like that.
But, we have seen what happens in smokeless tobacco from the nicotine.
We've done lots and lots of studies on animals to see how the brain develops in animals, and what we can see is there's a real strong correlation between the affects of nicotine and the effects we see on human studies that are using nicotine, in human subjects that are using nicotine as well.
So in other words, they're consistent with each other.
Now, let's talk about one other thing here for a second and that is, what do you do about nicotine in pregnancy and nicotine replacement? And how do you get women to quit? Well, first of all 40 women who are pregnant, 40% of women who are pregnancy find that to be a powerful motivator and they will in fact quit smoking.
An unstressingly amount of them will go back to smoking once the baby's born, which doesn't help the baby a whole lot either, but they will quit during pregnancy.
Nicotine replacement therapy has been something that medicine has used a long time to help people quit smoking, but both ACOG and the FDA say that's a last choice in pregnancy, because we just don't want to expose the fetus to nicotine.
Well, what about harm reduction.
The concept is here that perhaps if we do something that's less dangerous, there will be fewer people that are hurt by it.
So, if we move people from tobacco to pure nicotine like in an E-cigarette that that's going to be good for them.
I just want to point out that the lowest possible risk is from quitting nicotine all together.
At that point, you've reduced your risk to zero in terms of the nicotine.
So E-cigarette are counted as great because they're going to reduce the harm.
But what happens with the 40% of women who successfully quit smoking, instead switch to E-cigarettes and still get the nicotine? I would just suggest that that's not going to be helpful for their baby and this case the harm reduction isn't really going to be a harm reduction at all.
So, this is just theoretical again.
This is smokeless tobacco again, because we don't have studies on E-cigarettes yet, but several studies, and I've just given you some quotes from a couple of them, have looked at the impact and what we see is the impact on fetal exposure mirrors what we see in animals, including adverse behavioral outcome, such as attention deficit disorders, disruptive behavioral disorders and other things that we all struggle with in the school system today.
And, I'm not going to spend much time but I just do want to mention that nicotine has an impact.
The receptors alone decrease the number of lung cells along size and volume, the lungs become less elastic and impacts the lungs too.
Okay, are there any studies then on children with E-cigarettes? And the answer is no, not yet.
But we've looked at this and second-hand smoke a lot, and we know that children who are exposed to second-hand smoke at the home, in the home have more difficulty with reading and arithmatic comprehension.
Their school test scores are lower, ah, and, so we know that there are effects from, from that.
We aren't absolutely certain that's just the nicotine, but it's certainly consistent with pure nicotine research in animals.
There is also a concept called third-hand smoke and third-hand smoke is what's left after the second-hand smoke dissipates.
So you smoke a cigarette in a room, the smoker gets the primary smoke, everybody else in the room gets the second-hand smoke that's just out in the room.
When the smoking stops, what happens to the smoke? Well, it goes some place.
Some of it's absorbed onto the walls, onto the ceiling.
Cigarette smoke is composed of lots and lots of little particles.
These particles fall like rain onto the carpeting.
When you have a little rug rat rolling around and anybody who's ever had an adorable six-month-old crawling around, of course, they never put their hand in their mouth, and they never touch anything on the floor.
And you can show that these kids have nicotine levels that are equal to our, almost equal to the kids that are exposed to second-hand smoke.
So when you move into an apartment where somebody has been smoking in that, that out gassing continues for six months to a year.
Everything that was absorbed onto the walls starts coming out again when the smoking stops.
Everything that's in the carpeting gets picked up and blown again through the air when you vacuum.
And if you're down on the carpeting, ah, the five-second rule doesn't apply because it's going to be full of nicotine.
Okay, last third-hand smoke.
What we know from that that's pure nicotine in a lot of cases and that sort of gives us a good clue that those sorts of things are still happening with nicotine.
And as mentioned earlier, ah, children get into these E-cigarette cartridges and 40% of the tobacco related calls and Poison Control Centers are related to nicotine.
So, and this is really alarming.
Now we're seeing this incredible increase in E-cigarette use in adolescents.
Adolescence is a time when higher cognitive functioning begins.
Nicotine impairs that.
Development of the prefrontal cortex, which is this area, this part of the brain, which is where our judgment comes in.
Um, and the receptors are a major influence on how this executive kind of control mechanism that we all have to control our impulses, ah, begin to occur.
This animal studies again show that nicotine has a major impact on the way that these, the brain develops at this point and adolescents are going to be really a problem with this.
And if we go back and think about just how many percentage of kids are using E-cigarettes, we've got a real cause for alarm here now.
Now, adolescents are also much more likely to become addicted to any substance they use.
DeFrance, a guy in Boston who's been studying this for a long time, just shows that nicotine really is the true gateway drug people become addicted to nicotine and that leads to experimentation with other, ah, ah, drugs.
He shows that an adolescence, meaning say from 14 to 18, smoking one cigarette a week for six weeks is enough to get 50% of the kids that are addicted, are addicted to it at that.
One cigarette a week for six weeks and 50% of kids become addicted.
But the really scary thing and the really kind of interesting thing is that about 5% of kids will literally become addicted on their first cigarette.
And he, he says you can pick those kids out because they'll tell you when they had that cigarette, it was the greatest sensation they'd ever felt.
For that moment, they felt better than they'd ever felt in their life.
And those kids are the ones that are going to get hooked really on just one cigarette.
Now, the other thing is is that we've now follow, had an opportunity, cigarettes have been out long enough to follow these kids over time.
And kids who use E-cigarettes but don't smoke and have never smoked are three to five times more likely to start smoking than kids who have never used E-cigarettes.
So they clearly are an initiator for the use of cigarettes as a whole.
So, well, doesn't that mean that this is addictive? I couldn't believe it.
They actually tried to make the claim, the state, the Legislature, that nicotine was not addictive.
God, I so wanted one of the, the Representatives to ask me a question about that, Senators, I guess it was, ask me a question about that.
I was just absolutely flabbergasted that anybody would make that claim.
But, let's go back and look at it.
I had the opportunity once to share the stage with Victor DeNoble.
He was one of the guys that used to work for the tobacco industry.
They hired him in the 1970's to produce a heart-safe cigarette.
Um, he says he was successful at it, but since Phillip Morris never really brought the cigarette out, we don't know if he was successful or not.
But, be that as it may.
He started studying.
He had to get the rats addicted to nicotine and he was using pure nicotine I.
and was just a steady drip.
He was having a little trouble with rats would kind of like it but they didn't seem to be very crazy about it.
And he was sitting in the cafeteria watching people smoke one day and he realized that people smoke intermittently.
They take a puff, they put the cigarette down.
They take a puff, put the cigarette down.
So he went back to the lab and changed his pump for the rats, so that it pulsed the nicotine and those rats went crazy for nicotine.
That pulsing creates a surge of dopamine, a drop off, a surge of dopamine and a drop off, and that leads to powerful addiction.
There are now dozens and dozens, if not hundreds of studies showing that nicotine is in fact addictive.
So, that, we ought to be able to put that aside.
Are there other substances in tobacco that also produce physical dependence? Certainly.
But it's nicotine that the tobacco industry manipulates.
One of those things that was in cigarettes is formaldehyde.
Formaldehyde is also found in tobacco.
Formaldehyde's that really great smelling stuff that they used to put the, the frogs and the rats in in your biology class to preserve it.
You have to wear gloves when you use it because it's a carcinogen.
It also is mildly addictive.
That is, you actually get physically dependent on it.
I can't imagine something that would be worse than that.
However, it's real value to the tobacco industry is that formaldehyde increases the addictiveness of nicotine.
So the more formaldehyde there is in a cigarette, the same amount of nicotine is more likely to make you addicted.
So, ammonium does the same thing and there's a fair amount of ammonium in cigarettes.
I haven't seen any reports about ammonium in E-cigarettes.
So the tobacco industry deliberately manipulates the content of other chemicals in the cigarettes to potentiate the nicotine and make it more addictive.
They wouldn't be doing that if nicotine weren't addictive in the first place.
They'd be manipulating whatever it is that really is addictive.
They're manipulating the nicotine.
Okay, so what about addiction.
Well, if you dabble with alcohol, about one out of every 10 people is going to become an alcoholic.
But hey, if you dabble with cocaine, about one out of every six people is going to get addicted to cocaine.
Okay, now take a second and just think about what the addictive potential is of nicotine.
And the answer is, that one out of every two is going to get hooked in the long run.
As I said half of them will be hooked in adolescences, one cigarette a week for six weeks, but you keep going and at least 50% of people are going to get hooked.
This isn't scientifically proven, I should say.
This is the opinion of the addiction experts at John Hopkins.
So I would take that as a reasonable effect.
Okay, what about quitting? Well, nicotine replacement, you may have already heard about that's the gum, the patch.
They make an inhaler now, a nasal squirter.
Different ways of replacing nicotine.
They work about 5% of the time.
The inhaler works a little bit better than that.
But the gum and the patch will help about 5% of people who quit smoking.
Some antidepressants have been tried and they'll help about 10% of people who quit smoking.
Chantix, which is the, another smoking aid will help about 20 % of people who quit smoking.
Counseling is in the 15-20% range and counseling and medication get up to 30%, sometimes 35%, in that range.
Ah, to put that in perspective, when a doctor tells a patient to quit, about 2% of people will quit.
So, I always used to say I'll take my 2%, but I'm not very effective at getting people to quit smoking, just by telling people to quit smoking.
I have to do something else.
So, what about E-cigarettes? Well, first of all let's point out that E-cigarettes are not FDA approved as a quit aid.
Let's also point out that no company has applied to the FDA to present data to say that they're a quit aid.
So making a claim that they're a quit aid is completely bogus from a scientific point of view or a regulatory point of view.
Now, you, it is important that you do long-term followup when you do these kinds of studies.
Your quit rate in 30 days is always going to be better than your quit rate at a year, always.
Um, survey with some other, early studies did that suggest that E-cigarettes could be a reasonable help in quitting, helping people quit smoking.
The trouble was there were methodological problems.
They didn't follow them long enough.
They didn't check to see that they were really quitting exactly.
They didn't double-check them.
Some of the questions that, were whether or not they still smoking.
So they didn't really get rid of the dual use group.
So, they kept working at the studies and the studies kept getting better and they eliminated the methodological problems and as they did, they began to see that there really was no impact.
That is, people using E-cigarettes did not quit at a greater rate.
And recently they did what is called a Meta-Analysis, which is one way of combining a whole bunch of different studies into a much larger number, so you get bigger numbers and you get better statistical probabilities because you've got more people.
And when they do that, they showed that E-cigarette users were actually 28% less likely to quit smoking than people who used other quit aids.
So, another thing is, is that 80% of E-cigarette users in several surveys, but somewhere between 60 and 80% also use traditional cigarettes.
That is, that they're dual users.
So they're really not getting the benefit of cigarette cessation anyway.
So, ah, first of all we can build a little bit.
We've been researching cigarettes for more than 40 years.
And we have learned a lot about how cigarettes cause disease, whether it's cancer, whether it's heart disease.
As I mentioned, some of the effects of the brain, but we're still really, research into pure E-cigarettes.
Still, there are some effects that have been shown.
So for example, at heart disease, one of the things you need to be able to do is to make the arteries open up, so when you're heart's stressed, your coronary arteries have to get larger so you can pump more blood to your heart too, and the heart can work harder.
You can't do that effectively if you've had nicotine in your system, because nicotine, wants the ability of an artery to open up.
It can't open it up.
It just stays stuck.
Now, you get under some stress and you can't get enough oxygen or blood going to the heart muscle, and that can cause a heart attack.
This is due to the adverse impact on the endothelium, and we know that nicotine actually kills endothelial cells.
When you give somebody nicotine and then filter their blood, you can find dead endothelial cells floating around their blood stream.
When the endothelium is damaged like that, it tears more easily just from the normal movement and then you start getting stuff from the blood stream into the artery wall, and that's how plaque forms.
Also, there are these things called platelets.
Platelets are little tiny cell particles and their function in the blood is to clump together, so when you get a cut, they clump and plug the end of the blood vessels like a cork in a bottle and stops the bleeding.
Which is why we tell people to take aspirin when they have a heart attack because aspirin tells the platelets don't clump, and we know people can get a heart attack because the blood literally clumps inside of the blood vessel, instead of when it's bleeding like it's supposed to, and that cork in a bottle can cause a heart attack because it stops the blood flowing through that artery into the heart.
We tell people to take an aspirin because it keeps the platelets from clumping together like that.
However, nicotine in the particles, particularly the particles which are in E-cigarettes, that's why you see the cloud of smoke.
Those particles tell the platelets to clump together faster so they make it worse.
Now, we actually do have one study that just came out in March of this year that showed people who used E-cigarettes had an increased risk of having a heart attack of 42% compared to people who didn't use the E-cigarettes.
So we now have one study.
That by the way is very consistent with the studies on second-hand smoke, which is about in the same ballpark.
So, harm reduction.
Well, my analogy is this.
You have a ten-story building, you jump off the building you really don't expect to survive.
I apologize, this has only nine stories if you count the roof.
I didn't have a ten-story building.
So my idea, my thought is, is, sure when you do E-cigarettes, you might be jumping out of the third floor instead of the tenth floor.
You're still likely to get hurt and you might survive.
That's harm reduction.
That's what they mean by harm reduction.
The best thing to do is to walk out on the ground floor because it's the safest way to get out of the building, not jumping.
Now, if the data on heart disease pans out the way I've outlined it, after all we only have a few studies and we're still working on this a lot, we only have to move that from the third to the fourth or fifth floor.
Okay, on my last slide and then I'll shut up, is that again, and this is a slide that Kris showed you earlier about this dramatic decrease in ah, of Montana of people using cigarettes.
But remember, I don't have, do I have a pointer on this thing? Oh yes, okay.
The, there's 30%, somewhere around here, is where the E-cigarette use is.
Now, stop and think about this.
Those kids are three to five times more likely to start smoking.
I don't know what's going to happen to this number, but with this dramatic increase in E-cigarette use, we may be seeing this bottom out and starting back up again.
Only the future will tell us that, but I'd be really alarmed at what we're seeing.
Sarah Shapiro: All right.
So, I'm Sara Shapiro, I work for Lewis and Clark Public Health and I'll be talking about the tobacco marketing, um, in Montana, specifically the point-of-sale marketing.
So each year 9.
6 billion dollars is spent on marketing tobacco.
That's 26 million dollars every day and that's over 1 million dollars an hour.
In Montana that's 30.
5 million dollars spent a year from big tobacco and 95% of that money is spent at the point-of-sale location.
So when I'm talking about point of sale, I'm talking about where we buy our milk.
Where we buy our soda.
Where we buy candy.
It's where tobacco is sold.
So that is at convenience stores, gas stations, pharmacies, etc.
So this also mainly what I'm talking about.
This is what you see when you're checking out of those places.
So you're being marketed to at all aspects of these locations, so this is the outside, the advertisements, the price discounts.
Inside you go look where the Slushies are, there's something about Marlboro.
By the ice cream you'll see it, and then you also see it near the drinks.
You see it on all angles.
No matter where you go you're going to see these advertisements.
Some price discounts right above where you're checking out.
And so I'm mainly going to talk about this power wall.
So this is where the majority of the tobacco products are located.
So when you go to check out you really can't miss it.
Raise your hand if you recognize this.
So big tobacco is targeting for specific groups.
They're targeting people who are using.
They want them to continue using the product.
People who quit, they want them to start using again.
Would be users, those are the social smokers, the every once in awhile, the when they're drinking smokers, and then youth, who is what I'll be talking about most of my presentation.
Nine out of ten tobacco users start before the age of 18 and once they start, most are hooked for a long time, or the rest of their life, and so they're trying to get these replacement smokers.
So I'll go over the tactics that are specific to big tobacco is specifically using to hook these populations.
The first is eye level is buy level so most of the tobacco products are in front of the counter are at about three feet, so that's definitely not my eye level.
It's a younger population's eye level and it's mixed in with the candy.
So they already know that kids are looking at the candy, looking at the bright colors and the flavors and ah, that is where they're putting these tobacco products, and so I'm talking a lot about cigarillos, the flavor chew, E-cigarettes as well.
So as you can see, it's at this young girl's eye level, mixed in with this gum.
So, the, the kid is at 45 inches and the poster is at 45 inches, the tobacco poster.
Another thing is flavors.
So E-cigarettes, cigarillos, they come in a million flavors.
There's bubble gum, fruit loops, strawberry, mango, root beer float.
So these are definitely flavors that are targeting the inner crowd that is looking for that candy already, and sometimes these are mixed in so they look like candy.
If you've seen the commercials recently, you can look them up and they look identical, and they also look identical because of the packaging.
A lot of these products have the really bright colored packaging, so it looks like candy.
Another tactic is price discounts, so younger populations tend to not have as much spare money.
So using discounts, coupons, buy one, get one free, um, helps it seem more affordable and seem like something they could try to hook people.
I'll read this quote.
It's "The industries extensive use of price-reducing promotions has led to higher rates of tobacco use among young people than would have occurred in the absence of these promotions.
" The U.
Surgeon General, 2012.
And so that's saying that these are working, that more people are using because of these price discounts.
So why are they going after youth? Is cause they want their replacement smokers.
So Phillip Morris, one of the main tobacco companies, has been noted saying "The ability to attract new smokers and develop them into a young adult franchise is key to brand development.
" So, they're older population is getting older, getting sick and they need to replace, they need to replace people who are going to use it for the rest of their lives.
So that is why they're going for youth.
Place is really important.
Can we raise our hands if you've been inside a gas station or convenience store in the last week.
So normally when I go to the gas station, I don't go inside any more.
I pay at the pump and I leave and I don't really go inside very often, but 70% of youth go into gas stations and convenience stores weekly.
So they're extremely vulnerable to this number, um, because of all the different advertisements.
They go during lunch to get candy.
They go on their walk home.
Um, it's kind of like a right of passage to be able to go to one of these places with your friends.
And so place is really important because of the amount of them in Helena alone and then Broadwater.
This is just our area and how many places you can see it and be victim to this advertising.
So adver, this pays off.
There's a reason that 30.
5 million dollars a year is spending in Montana.
So each day 3,300 youth under the age of 18 will try their first cigarette, 700 of these children will become regular smokers.
So it's a scary number.
Um, but it's showing that this advertising is working.
And again this is another graph showing that same thing.
It's showing how the green bars are showing the dollars spent on E-cigarette advertising and the line is showing the past 30 day great use among youth, and as you can see, as advertising goes up, so is the use among youth.
So this is just another graph showing that um, the amount of E-cigarette users is going up every year.
So this tobacco marketing is working and why we should be scared of it is because it normalizes the presence of tobacco products, meaning when youth go into these locations and they see how much tobacco is and where it is all over the place, it seems like more people are using it.
And when more people use it, the way to fit in.
So, it normalizes the idea of it.
It encourages youth to use tobacco and eventually get hooked.
It makes it harder for current users to quit.
You know they want to buy the milk, but they're seeing this tobacco product every time they try to check out.
It encourages people who quit tobacco to start using again.
So these are some pictures that I did from a recent scavenger hunt that I've been doing with the youth.
What I do is I take youth to these different locations and they have check marks and they have to check if they see products below three feet, what flavors they're seeing, what discounts are seen.
Can you see it from the road.
Things like that.
And so I'm able to work with youth to understand this and it tends to be empowering because they don't like being targeted.
You know, they want that independence and that freedom, and so they don't like how these companies are targeting them.
Um, I'm also doing presentations to multiple groups trying to get the word out because once you learn these tactics it's really hard to not notice them.
So that's one thing I encourage everyone here to do, is to go into these stores and notice them and realize them, and then tell your friends.
Tell your peers.
Tell the youth, um, to keep educating.
Nicole Aune: So, I'm just going to do a final wrap up here and kind of leave us with, so now what.
We've heard all these things.
What do we do next? What are our actions steps? So, just to talk a little bit about the, the laws that are in place now.
In January of 2016 Montana set a law that you have to be 18 in order to purchase E-cigarettes.
Before that anybody, any age, could go and get these.
You could be 7 years old and walk into a store and be able to buy an E-cigarette, which is just absolutely atrocious.
So at least now we do have that law in place.
That was set here in the state in January of 2016 and then the FDA came and set it, set a law in May of 2016 at the national level.
So now that's a national law that you have to be 18 in order to purchase these products.
Um, they are also not allowed to be sold in vending machines where kids can, where kids are present.
Um, they're not allowed to give out free samples.
And starting in May of 2018, um, if we get there with this administration, um, warning labels ah are, are going to be required.
And I thought that this, this is kind of interesting this warning label right here, because um, it, you'll hear as Dr.
Shepard said many times, you hear the E-cigarette industry saying, oh nicotine is, is actually good for you.
It's not harmful at all.
So, now you're being required to put a warning label on that explicitly states that nicotine is harmful and extremely addictive.
So, just putting that out there.
So then, we actually have some other laws here in, in Montana.
So we've had a few counties that have taken it upon themselves to include E-cigarettes in their local Clean Indoor Air Act protocols and actually Lewis and Clark County was the first county to do that.
So, yeah, Lewis and Clark County.
Round of applause.
And there are actually four other counties now from Montana that have E-cigarettes in their Clean Indoor Air Act protocol.
That's Sanders County, Carbon, Powell, and Granite recently added there then too.
I'll just mention too that in addition to those businesses in other, in other counties where this isn't a law, businesses have the authority and, and the um, and the right to ban E-cigarettes in their business.
So different businesses or housing authorities, um, hospitals, they can, they can choose to ban the use of E-cigarettes on their property.
So I did want to mention that lots of other localities across the national have taken it upon themselves to enact some policies that are even, even more strict on these products, and help protect our youth.
So in California, and Hawaii, they have made it illegal to purchase any tobacco product, including E-cigarettes, um, if you (cough) (excuse me) if you are under the age of 21.
So there are at least 225 other localities where it's illegal to purchase tobacco if you're under the age of 21.
So this is really good for a number of reasons.
Um, one is because it reduces, or it delays the age of initiation and then two, it helps keep tobacco out of schools, um, as Kris had mentioned earlier.
You have, have 18 year olds who can buy these products and they're still in high school.
When you raise the age to 21, you don't have a lot of 21 year olds who are still in high school, so it makes it difficult for those kids to be buying a tobacco product or E-cigarettes and passing along to their friends in high school.
And then the other reason is, um, it reduces sales to minors because it's harder to pass off as a 21 year old than it is to pass off as an 18 year old.
So, so doing that, that's a really, that's a really good policy that the Surgeon General promotes.
In Minnesota, they've applied a tax to E-cigarettes.
You heard Dr.
Shepard talk about how we've, we recently tried to do that and it didn't go so well.
But raising the price, raising the price on tobacco products is one of the most effective mechanisms to re, to prevent youth initiation of tobacco products.
So, like some other, um, some of our counties in Montana, New Jersey and our neighbor North Dakota, the whole state has prohibited the use of E-cigarettes in indoor public places.
So that's something that a whole state can do, is, is include that in the state Clean Indoor Air Act.
Um, Chicago has actually banned the sale of flavored products within 500 feet of a school.
So they're taking action on these flavors, because E-cigarettes, they come in 7,700 different flavors.
I mean, that, that's insane and, as Sarah mentioned, they're in all these different flavors that are appealing specifically to kids.
Um, Providence, Rhode Island has prohibited discounts like coupons and buy one, get one free.
And then New York City has actually had a law that requires that all of their tobacco products be placed behind the counter or in another area that's not freely accessible and can't just be picked up by a kid and walked out.
So this is just kind of a sample.
There are a lot of other localities across the nation that have taken action like this.
This is just a sample of some of the, some of the policies that are in place across the nation.
So what can you do? What we're wanting from the community outright is to, to know the facts so you've taken the right step today coming and hearing, hearing what we do know about E-cigarettes, so I applaud you for doing that.
The other thing is, talk to your kids and other young people about the risks associated with E-cigarettes, not just water vapor and now you guys know that.
And you know, find the right time to talk to them.
It may not just be, oh I'm going to pull my kid aside and we're going to have a sit down conversation in our living room.
Maybe take the opportunity when you're in a convenience store with your kid or with another young person, and you're seeing those tobacco products placed right next to the candy bars.
Take that moment to stop and say, "hey what do you think about this?" And get their thoughts on it.
Or if you see somebody, you're walking by somebody who's using an E-cigarette or if you're hearing, hearing advertisements on E-cigarettes.
Um, the other thing is, you know, reach out to other, other adults and, and talk to your decision makers, educate your decision makers about these products.
Like, like I said at the very beginning, there's so much misinformation about these products and depending on who you talk to, you're getting different types of, of facts.
So, it's really important that you're communicating to your decision makers and your legislatures, the real facts about these, about these E-cigarettes and what they're doing to our kids and why we're, why we're concerned.
And this can look at, look in a lot of different ways, it could, it could also take the form of, you know, writing, writing a letter to the editor for your newspaper, going and speaking at different groups.
So, so just getting, getting your voice out there is a good way too.
And the last one that I'd like to mention is, is really important, is lead by example.
You know, be tobacco-free yourself.
So if, if you are a tobacco user, there is help for you.
There's a Montana Tobacco Quit Line.
It offers free nicotine replacement therapy which is little gums and gum and lozenges and patches.
It offers reduced cost medication and free coaching.
These, these things like Dr.
Shepard mentioned, combined offer you the greatest success rate that you can get.
So there is help for you and, and it doesn't help to, it's harder for you to have a conversation with your kids about tobacco products and E-cigarettes, if you yourself are using them.
It's harder to get that message across.
So there is hope for you and your set, 1-800-QUIT-Now.
(Redirected from Health effects of electronic cigarettes)
The safety of electronic cigarettes is uncertain. There is little data about their safety, and considerable variability among e-cigarettes and in their liquid ingredients and thus the contents of the aerosol delivered to the user. Reviews on the safety of e-cigarettes have reached significantly different conclusions. A 2014 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 likely safer than e-cigarettes,. A systematic review suggests that e-cigarettes are less harmful than smoking and since they contain no tobacco and do not involve combustion, users may avoid several harmful constituents usually found in tobacco smoke. However, e-cigarettes cannot be considered harmless.
E-cigarettes have been found to reduce lung and myocardial function, increase inflammation, and have toxic content including carcinogens, but to a much lower extent than combustible cigarettes in virtually all cases. The long-term effects of e-cigarette use are unknown. A 2015 study found serious adverse events related to e-cigarettes were hypotension, seizure, chest pain, rapid heartbeat, disorientation, and congestive heart failure but it was unclear to the degree they were the result of e-cigarettes. Less serious adverse effects may include abdominal pain, headache, blurry vision, throat and mouth irritation, vomiting, nausea, and coughing. A 2014 WHO report said, "ENDS [electronic nicotine delivery system] use poses serious threats to adolescents and fetuses." Aside from toxicity exposure in normal use, there are also risks from misuse or accidents such as nicotine poisoning (especially among infants and children), contact with liquid nicotine, fires caused by vaporizer malfunction, and explosions resulting 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 cytotoxicity of e-liquids varies, and contamination with various chemicals have been detected in the liquid. Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals. Many chemicals including carbonyl compounds such as formaldehyde can inadvertently be produced when the nichrome wire (heating element) that touches the e-liquid is heated and chemically reacted with the liquid. Normal usage of e-cigarettes, and reduced voltage (3.0 V) devices generate very low levels of formaldehyde. Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[Notes 1] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage. A 2015 Public Health England (PHE) report found that high levels of formaldehyde only occurred in overheated "dry-puffing". Users detect the "dry puff" and avoid it, and they concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes." However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough. E-cigarette users who use devices 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.
E-cigarettes create an aerosol that consists of fine and ultrafine particles of particulate matter, with the majority of particles in the ultrafine range. The vapor have been found to contain flavors, propylene glycol, glycerin, nicotine, tiny amounts of toxicants, carcinogens, heavy metals, and metal nanoparticles, and other substances. Exactly what the vapor comprises varies in composition and concentration across and within manufacturers. E-cigarette vapor potentially contains harmful substances not found in tobacco smoke. The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor. E-cigarette vapor contains lower concentrations of potentially toxic chemicals than with cigarette smoke. Those which are present, are mostly below 1% the corresponding levels permissible by workplace safety standards. But workplace safety standards do not recognize exposure to certain vulnerable groups such as people with medical ailments, children, and infants who may be exposed to second-hand vapor. Concern exists that some of the mainstream vapor exhaled by e-cigarette users may 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.
Reviews on the safety of e-cigarettes, evaluating roughly the same studies, have reached significantly different conclusions. Due to various methodological issues, severe conflicts of interest, and inconsistent research, no definite conclusions can be determined regarding the safety of e-cigarettes. However, e-cigarettes cannot be regarded as harmless. There is little data about their safety, and considerable variability among vaporizers and in their liquid ingredients and thus the contents of the aerosol delivered to the user. The health community, pharmaceutical industry, and other groups have raised concerns about the emerging phenomenon of e-cigarettes, including the unknown health risks from long-term use of e-cigarettes. Concern exists that the majority of smokers attempting to quit by vaping may stop smoking but maintain nicotine intake because their long-term effects are not clear. A policy statement by the American Association for Cancer Research and the American Society of Clinical Oncology has reported that "The benefits and harms must be evaluated with respect to the population as a whole, taking into account the effect on youth, adults, nonsmokers, and smokers." A July 2014 World Health Organization (WHO) report cautioned about the potential risks to children and adolescents, pregnant women, and women of reproductive age regarding e-cigarette use.
It is recommended the precautionary principle be used for e-cigarettes because of the long history of the tobacco crisis, in order to assess their benefits and long-term effects and to avoid another nicotine crisis. A 2014 review recommended that e-cigarettes could be adequately regulated for consumer safety with existing regulations on the design of electronic products. Regulation of the production and promotion of e-cigarettes may help lower some adverse effects associated with tobacco use. The entrance of large US tobacco manufacturers, which are Altria Group, Reynolds American, and Lorillard, into the e-cigarette sector raises many potential public health issues. Instead of encouraging quitting, the tobacco industry could market e-cigarettes as a way to get around clean indoor air laws, which promotes dual use. The industry could also lead vapers to tobacco products, which would increase instead of decrease overall addiction.
The health effects related to e-cigarette use is mostly unknown. The health effects on intensive e-cigarette users are unknown. The effect on population health from e-cigarettes is unknown. Smokefree.gov, a website run by the Tobacco Control Research Branch of the National Cancer Institute to provide information to help quit smoking, stated that "Since e-cigs aren’t regulated yet, there’s no way of knowing how much nicotine is in them or what other chemicals they contain. These two things make the safety of e-cigs unclear." The English National Health Service has stated, "While e-cigarettes may be safer than conventional cigarettes, we don’t yet know the long-term effects of vaping on the body." The American Diabetes Association states "There is no evidence that e-cigarettes are a healthier alternative to smoking." In August 2014, the Forum of International Respiratory Societies stated that e-cigarettes have not been demonstrated to be safe.Health Canada has stated that, "their safety, quality, and efficacy remain unknown." The National Institute on Drug Abuse stated that "There are currently no accepted measures to confirm their purity or safety, and the long-term health consequence of e-cigarette use remain unknown."
Effects of vaping, compared to tobacco smoking.
A 2015 Public Health England (PHE) report stated that e-cigarettes are estimated to be 95% less harmful than smoking, although this estimate has been disputed. In June 2014, the Royal College of Physicians stated that, "On the basis of available evidence, the RCP believes that e-cigarettes could lead to significant falls in the prevalence of smoking in the UK, prevent many deaths and episodes of serious illness, and help to reduce the social inequalities in health that tobacco smoking currently exacerbates." A 2014 systematic review suggests that e-cigarettes are less harmful than smoking because there is no tobacco, no combustion, and users may avoid several harmful constituents usually found in tobacco smoke. A 2014 review found that e-cigarette aerosol contains far fewer carcinogens than tobacco smoke, and concluded that e-cigarettes "impart a lower potential disease burden" than traditional cigarettes. Scientific studies advocate caution before designating e-cigarettes as beneficial but vapers continue to believe they are beneficial.
The American Cancer Society has stated, "The makers of e-cigarettes say that the ingredients are "safe," but this only means the ingredients have been found to be safe to eat. Inhaling a substance is not the same as swallowing it. There are questions about how safe it is to inhale some substances in the e-cigarette vapor into the lungs." The Canadian Cancer Society has stated that, "A few studies have shown that there may be low levels of harmful substances in some e-cigarettes, even if they don’t have nicotine." In the UK a National Institute for Health and Care Excellence (NICE) guideline did not recommend e-cigarettes as there are questions regarding the safety, efficacy, and quality of these products. The US National Association of County and City Health Officials has stated, "Public health experts have expressed concern that e-cigarettes may increase nicotine addiction and tobacco use in young people." No long-term studies have evaluated future tobacco use as a result of e-cigarette use. E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.
Possible adverse effects of vaping.
As of 2015, the short-term and long-term effects from using e-cigarettes remain unclear.Adverse effects are mostly associated with short-term use and the reported adverse effects decreased over time. Long-term studies regarding the effects of constant use of e-cigarettes are unavailable. The adverse effects of e-cigarettes on people with cancer is unknown. A 2014 Cochrane review found no serious adverse effects reported in trials, but serious events have been reported in case studies.
The evidence suggests they produce less harmful effects than combusted tobacco. The most frequently reported less harmful effects of vaping compared to smoking were reduced shortness of breath, reduced cough, reduced spitting, and reduced sore throat. Many health benefits are associated with switching from tobacco to e-cigarettes including decreased weight gain after smoking cessation and improved exercise tolerance. Vaping is possibly harmful by virtue of putting off quitting smoking, serving as a gateway to tobacco use in never-smokers or causing a return to smoking in former smokers. Many people use e-cigarettes to quit smoking, but few succeed. They frequently use both, which increases their health risks by using both products. Quitting smoking entirely would probably have much greater beneficial effects to overall health than vaping to decrease the number of cigarettes smoked.
More serious adverse effects frequently related with smoking cessation including depression, insomnia, and anxiety are uncommon with e-cigarette use. A 2015 study found serious adverse events related to e-cigarettes were hypotension, seizure, chest pain, rapid heartbeat, disorientation, and congestive heart failure but it was unclear to the degree they were the result of e-cigarettes. Less serious adverse effects include abdominal pain, headache, blurry vision, throat and mouth irritation, vomiting, nausea, and coughing. Short-term adverse effects reported most often were mouth and throat irritation, dry cough, and nausea. The majority of adverse effects reported were nausea, vomiting, dizziness and oral irritation. Some case reports found harms to health brought about by e-cigarettes in many countries, such as the US and in Europe; the most common effect was dryness of the mouth and throat. Some e-cigarettes users experience adverse effects like throat irritation which could be the result of exposure to nicotine, nicotine solvents, or toxicants in the aerosol.
The US Food and Drug Administration Center for Tobacco Products reported between 2008 and the beginning of 2012, 47 cases of adverse effects associated with e-cigarettes, of which eight were considered serious. Two peer-reviewed reports of lipoid pneumonia were related to e-cigarette use, as well as two reports in the media in Spain and the UK. The man from the UK reportedly died from severe lipoid pneumonia in 2011. Reports to the Food and Drug Administration (FDA) for minor adverse effects identified with using e-cigarettes include headache, chest pain, nausea, and cough. Major adverse effects reported to the FDA included hospitalizations for pneumonia, congestive heart failure, seizure, rapid heart rate, and burns. However no direct relationship has been proven between these effects and e-cigarette use, and some of them may be due to existing health problems. Many of the observed negative effects from e-cigarette use concerning the nervous system and the sensory system are probably related to nicotine overdose or withdrawal. Since e-cigarettes are intended to be used repeatedly, they can conveniently be used for an extended period of time, which may contribute to increased adverse effects. E-cigarettes were associated with fewer adverse effects than nicotine patches.
Symptoms of nicotine poisoning related to e-cigarette calls to US poison control centers.
Nicotine poisoning related to e-cigarettes include ingestion, inhalation, or absorption via the skin or eyes. Accidental poisoning can result from using undiluted concentrated nicotine when mistakenly used as prepared e-liquids. E-cigarettes involve accidental nicotine exposure in children. Accidental exposures in pediatric patients include ingesting of e-liquids and inhaling of e-cigarette vapors. Choking on e-cigarette components is a potential risk. It is recommended that youth access to e-cigarettes be prohibited.
Four adults died in the US and Europe, after intentionally ingesting liquid. Two children, one in the US in 2014 and another in Israel in 2013, died after ingesting liquid nicotine. Death from accidental nicotine poisoning is very uncommon.
Calls to US poison control centers related to e-cigarette exposures involved inhalations, eye exposures, skin exposures, and ingestion, in both adults and young children. Minor, moderate, and serious adverse effects involved adults and young children. Minor effects correlated with e-cigarette liquid poisoning were tachycardia, tremor, chest pain and hypertension. More serious effects were bradycardia, hypotension, nausea, respiratory paralysis, atrial fibrillation and dyspnea. The exact correlation is not fully known between these effects and e-cigarettes. 58% of e-cigarette calls to US poison control centers were related to children 5 years old or less. E-cigarette calls had a greater chance to report an adverse effect and a greater chance to report a moderate or major adverse effect than traditional cigarette calls. Most of the e-cigarette and traditional cigarette calls were a minor effect. Severe outcomes were more than 2.5 times more frequent in children exposed to e-cigarettes and nicotine e-liquid than with traditional cigarettes. E-cigarette sales were roughly equivalent to just 3.5% of traditional cigarette sales, but of the total number of e-cigarette and traditional cigarette calls to US poison control centers in December 2014, the reported e-cigarettes calls were 44%.
Poison control center calls in the US related to e-cigarettes was one call per month in September 2010 to over 200 calls per month in February 2014.
From September 1, 2010 to December 31, 2014, the most frequent adverse effects to e-cigarettes and e-liquid reported to US poison control centers were: Ingestion exposure resulted in vomiting, nausea, drowsy, tachycardia, or agitation; inhalation/nasal exposure resulted in nausea, vomiting, dizziness, agitated, or headache; ocular exposure resulted in eye irritation or pain, red eye or conjunctivitis, blurred vision, headache, or corneal abrasion; multiple routes of exposure resulted in eye irritation or pain, vomiting, red eye or conjunctivitis, nausea, or cough; and dermal exposure that resulted in nausea, dizziness, vomiting, headache, or tachycardia. The ten most frequent adverse effects to e-cigarettes and e-liquid reported to US poison control centers were vomiting (40.4%), eye irritation or pain (20.3%), nausea (16.8%), red eye or conjunctivitis (10.5%), dizziness (7.5%), tachycardia (7.1%), drowsiness (7.1%), agitation (6.3%), headache (4.8%), and cough (4.5%). In nine reported calls, exposed individuals stated the device leaked. In five reported calls, individuals used e-liquid for their eyes rather than use eye drops. In one reported call, an infant was given the e-liquid by an adult who thought it was the infant's medication. There were also reports of choking on e-cigarette components.
From January 1, 2016 and April 30, 2016, the American Association of Poison Control Centers (AAPCC) reported 623 exposures related to e-cigarettes. The AAPCC reported 3,067 exposures relating to e-cigarettes and liquid nicotine in 2015, and 3,783 in 2014. From September 1, 2010 to December 31, 2014, there were at least 5,970 e-cigarette calls to US poison control centers. Calls to US poison control centers related to e-cigarettes increased between September 2010 to February 2014, and of the total number of cigarettes and e-cigarettes calls, e-cigarette calls increased from 0.3% to 41.7%. Calls to US poison controls centers related to e-cigarette liquid poisoning increased from 1 in September 2010 to 215 for the month of February 2014. E-cigarette calls was 401 for the month of April 2014. The California Poison Control System reported 35 cases of e-cigarette contact from 2010 to 2012, 14 were in children and 25 were from accidental contact.
Fruit flavored e-liquids.
There is a possibility that inhalation, ingestion, or skin contact can expose people to high levels of nicotine. Concerns with exposure to the e-liquids include leaks or spills and contact with contaminants in the e-liquid. This may be especially risky to children, pregnant women, and nursing mothers. The liquid quickly absorbs into the skin. The nicotine in e-liquid can be hazardous to infants. Even a portion of e-liquid may be lethal to a little child. An excessive amount of nicotine for a child that is capable of being fatal is 0.1–0.2 mg/kg of body weight. Less than a 1 tablespoon of contact or ingestion of e-liquid can cause nausea, vomiting, cardiac arrest, seizures, or coma. An accidental ingestion of only 6 mg may be lethal to children.
Children are susceptible to ingestion due to their curiosity and desire for oral exploration. E-cigarettes are packed in colorful containers and children may be attracted to the flavored liquids. More youth-oriented flavors include "My Birthday Cake" or "Tutti Frutti Gumballs". Many nicotine cartridges and bottles of liquid are not child-resistant to stop contact or accidental ingestion of nicotine by children. "Open" e-cigarette devices, with a reﬁllable tank for e-liquids, are believed to be the biggest risk to young children. It is recommended that e-cigarettes be kept in a safe place, where children and pets do not have access to them.
Nicotine toxicity is of concern when e-cigarette solutions are swallowed intentionally by adults as a suicidal overdose. Six people attempted suicide by injecting e-liquid. One adolescent attempted suicide by swallowing the e-liquid. Three deaths were reported to have resulted from swallowing or injecting e-liquid containing nicotine. An excessive amount of nicotine for an adult that is capable of being fatal is 0.5–1 mg/kg of body weight. An oral lethal dose for adults is about 30–60 mg. However the widely used human LD50 estimate of around 0.8 mg/kg was questioned in a 2013 review, in light of several documented cases of humans surviving much higher doses; the 2013 review suggests that the lower limit resulting in fatal events is 500–1000 mg of ingested nicotine, which is equivalent to 6.5–13 mg/kg orally. Reports of serious adverse effects associated with acute nicotine toxicity that resulting in hospitalization were very uncommon. Death from intentional nicotine poisoning is very uncommon. Clear labeling of devices and e-liquid could reduce unintentional exposures. Child-proof packaging and directions for safe handling of e-liquids could minimize some of the risks. In January 2016, the Child Nicotine Poisoning Prevention Act of 2015 was passed into law in the US, which requires child-proof packaging.
There was inconsistent labeling of the actual nicotine content on e-liquid cartridges from some brands, and some nicotine has been found in ‘no nicotine' liquids. A 2015 PHE report noted overall the labelling accuracy has improved. Most inaccurately-labelled examples contained less nicotine than stated. Due to nicotine content inconstancy, it is recommended that e-cigarette companies develop quality standards with respect to nicotine content.
Because of the lack of production standards and controls, the pureness of e-liquid are generally not dependable, and testing of some products has shown the existence of harmful substances. The German Cancer Research Center in Germany released a report stating that e-cigarettes cannot be considered safe, in part due to technical flaws that have been found. This includes leaking cartridges, accidental contact with nicotine when changing cartridges, and potential of unintended overdose. The Therapeutic Goods Administration (TGA) of Australia has stated that, "Some overseas studies suggest that electronic cigarettes containing nicotine may be dangerous, delivering unreliable doses of nicotine (above or below the stated quantity), or containing toxic chemicals or carcinogens, or leaking nicotine. Leaked nicotine is a poisoning hazard for the user of electronic cigarettes, as well as others around them, particularly children."
Cannabinoid-containing e-liquids need lengthy, complex processing, some being available online without any toxicological and clinical evaluation. It is thought that cannabinoids vaped at reduced temperatures is safer because it creates smaller amounts of toxicants than the burning of a hot cannabis cigarette. The health effects of vaping cannabis formulations is mostly unknown.
Most e-cigarettes use lithium batteries, the improper use of which may result in accidents. It has been recommended that manufacturing quality standards be imposed in order to prevent such accidents. Better product design and standards could probably reduce some of the risks. Concern exists from risks associated with e-cigarette explosions for children and adults.
Some batteries are not well designed, are made with poor quality components, or have defects. Major injuries have occurred from battery explosions and fires. A man endured a unilateral corneoscleral laceration with prolapsed iris tissue and hyphemato to the eye area when an e-cigarette exploded in his mouth. A young man endured bilateral corneal burns to the eye area when an e-cigarette exploded near his chest. E-cigarette explosions have resulted in burns, lost teeth, neck fractures, and battery acid contact to the face, mouth, and eyes. A man died when charging an e-cigarette blown up and caught on fire next to oxygen equipment. House and car fires and skin burns have resulted from some of the explosions. The explosions were the result of extended charging, use of unsuitable chargers, or design flaws. There is a possible risk to bystanders from e-cigarette explosions. There is also a risk of property damage as a result of flammable materials catching on fire from an e-cigarette explosion. The United States Fire Administration said that 25 fires and explosions were caused by e-cigarettes between 2009 and August 2014. In the UK fire service call-outs had risen, from 43 in 2013 to 62 in 2014. A 2015 PHE report concluded that the risks of fire from e-cigarettes "appear to be comparable to similar electrical goods". Since e-cigarettes are not subjected to product safety testing, they may not have safety designs to avoid overheating, thermal runaway, and battery failure including fire and explosions. There is inadequate product labeling to inform users of the possible serious harms. The risk from serious adverse effects is low, but the aftermath may be disastrous in respect to an e-cigarette blast. Victims have filed lawsuits to make restitution from the e-cigarette blasts. Adverse effects may be under-reported because reports to the FDA is voluntary.
In January 2015 the US Federal Aviation Administration issued a safety alert to air carriers that e-cigarettes should not be allowed in checked baggage after a review of fire safety issues, including two fires caused by e-cigarettes in checked baggage. The International Civil Aviation Organization, a United Nations agency, also recommends prohibiting e-cigarettes in checked luggage. A spokesman for the Tobacco Vapor Electronic Cigarette Association said that e-cigarettes do not pose a problem if they are packed correctly in static-free packaging, but that irresponsible people may sometimes pack them carelessly or tamper with them. In-flight use of e-cigarettes is prohibited in the US.
Users may alter many of the devices, such as using them to administer other drugs like cannabis. E-liquid mixing is another way users tamper with e-cigarettes. Mixing liquid in an unclean area runs the risk of contamination. Users may add various flavorings and diluents. Vodka or other forms of alcohol may also be added. The addition of alcohol or nicotine could expose the user to more toxicants, especially when added in combinations. Some ingredients in e-liquids could be flammable; this risk is more of concern for users who are inexperienced or do not use protective gear. Users can adjust the voltage of some e-cigarettes. The amount of vapor produced is controlled by the power of the battery, which has led some users to adjust their e-cigarettes to increase battery power to obtain a stronger nicotine "hit", but there is a small risk of battery explosion. Some users add more or larger batteries to nonadjustable e-cigarettes, which may lead to battery leakage or explosion. The extent to which teens are altering e-cigarettes, such as dripping the liquids onto the atomizer to get more nicotine intake, is not known.
The long-term health impacts of e-cigarette use are unknown. The long-term health impacts of the main chemicals nicotine and propylene glycol in the aerosol are not fully understood. There is limited peer-reviewed data about the toxicity of e-cigarettes for a complete toxicological evaluation, and their cytotoxicity is unknown. The chemicals and toxicants included in e-cigarettes have not been completely disclosed and their safety is not guaranteed. They are similar in toxicity to other nicotine replacement products, but e-cigarettes manufacturing standards are variable standards, and many as a result are probably more toxic than nicotine replacement products. The UK National Health Service noted that the toxic chemicals found by the FDA were at levels one-thousandth that of cigarette smoke, and that while there is no certainty that these small traces are harmless, initial test results are reassuring. While there is variability in the ingredients and concentrations of ingredients in e-cigarette liquids, tobacco smoke contains thousands of chemicals, most of which are not understood and many of which are known to be harmful.
Concerns about the carcinogenicity of e-cigarettes arise from both nicotine and from other chemicals that may be in the vapor. As regards nicotine, there is evidence from in vitro and animal research that nicotine may have a role as a tumor promoter, but carcinogenicity has not been demonstrated in vivo. A 2014 Surgeon General of the United States report stated that the single relevant randomized trial "does not indicate a strong role for nicotine in promoting carcinogenesis in humans". They concluded that "There is insufficient data to conclude that nicotine causes or contributes to cancer in humans, but there is evidence showing possible oral, esophageal, or pancreatic cancer risks". Nicotine in the form of nicotine replacement products is less of a risk than compared to smoking, and they have not been shown to be associated with cancer in the real world.
There is no long-term research concerning the cancer risk related to the potentially small level of exposure to the identified carcinogens in the vapor. In May 2014, Cancer Research UK stated that there are "very preliminary unpublished results that suggest that e-cigarettes promote tumour growth in human cells." The e-cigarette vapors triggered DNA strand breaks and lowered cell survival in vitro. A 2013 study found some samples of e-cigarette vapors had cytotoxic effects on cardiac muscle cells, though the effects were less than with cigarette smoke. In October 2012, the World Medical Association stated, "Manufacturers and marketers of e-cigarettes often claim that use of their products is a safe alternative to smoking, particularly since they do not produce carcinogenic smoke. However, no studies have been conducted to determine that the vapor is not carcinogenic, and there are other potential risks associated with these devices."
Chart showing various toxicants as measured in cigarette smoke and e-cigarette aerosol.
Since nicotine-containing e-liquids are made from tobacco they may contain impurities like cotinine, anabasine, anatabine, myosmine and beta-nicotyrine. The majority of e-cigarettes evaluated included carcinogenic tobacco-specific nitrosamines (TSNAs); heavy metals such as cadmium, nickel, and lead; and the carcinogen toluene. However, in comparison to traditional cigarette smoke, the toxic substance levels identified in e-cigarette vapor were 9- to 450-fold less. E-liquid with tin was cytotoxic. E-cigarettes cannot be considered absolutely safe because there is no safe level for carcinogens.
A 2014 review found higher levels of carcinogens and toxicants than in an FDA-approved nicotine inhaler, suggesting that FDA-approved devices may deliver nicotine more safely. In 2014, The World Lung Foundation stated that "Researchers find that many e-cigarettes contain toxins, contaminants and carcinogens that conflict with the industry’s portrayal of its products as purer, healthier alternatives. They also find considerable variations in the amount of nicotine delivered by different brands. None of this information is made available to consumers so they really don’t know what they are ingesting, or how much."
A 2014 review found "Various chemical substances and ultrafine particles known to be toxic, carcinogenic and/or to cause respiratory and heart distress have been identified in e-cigarette aerosols, cartridges, refill liquids and environmental emissions." Few of the methods used to analyze the chemistry of e-cigarettes in the studies the review evaluated were validated.
The propylene glycol molecule.
The primary base ingredients of the liquid solution is propylene glycol and glycerin. About 20% to 27% of propylene glycol and glycerin-based liquid particles are inhaled. The long-term effects of inhaled propylene glycol has not been studied, and is unknown. The effects of inhaled glycerin are unknown. Being exposed to propylene glycol may cause irritation to the eyes and respiratory tract. The risk from the inhalation of propylene glycol and glycerin is probably low. Propylene glycol and glycerin have not been shown to be safe. Some research states that propylene glycol emissions may cause respiratory irritation and raise the likelihood to develop asthma. Long-term inhalation of propylene glycol indoors could increase risk to children to develop asthma. To lessen the risks, most e-cigarettes companies began to use water and glycerin as replacement for propylene glycol. The inhaled glycerin could cause lipoid pneumonia.
Some e-cigarette products had acrolein identified in the aerosol. It may be generated when glycerin is heated to higher temperatures. Acrolein may induce irritation to the upper respiratory tract. Acrolein levels were reduced by 60% in dual users and 80% for those that completely switched to e-cigarettes when compared to traditional cigarettes. E-cigarettes vapor have been found to create oxidants and reactive oxygen species (OX/ROS). OX/ROS could react with other substances in the vapor because they are highly reactive. Although e-cigarettes have been found to contain OX/ROS at about 100 times less than in cigarette smoke, they probably induce meaningful biological effects.
The toxicity of e-cigarettes and e-liquid can vary greatly, as there are differences in construction and materials in the delivery device, kind and origin of ingredients in the e-liquid, and the use or non-use of good manufacturing practices and quality control approaches. If exposure of aerosols to propylene glycol and glycerin rises to levels that one would consider the exposure in association with a workplace setting, it would be sensible to investigate the health of exposed persons. The short-term toxicity of e-cigarette use appears to be low, with the exception for some people with reactive airways.
The ingredients in an e-cigarette cartridge: Distilled water, Nicotine, FCC Grade Vegetable Glycerin, Natural Flavors, Artificial Flavors, Citric Acid. Nicotine content 6-8 mg per cartridge.
The essential propylene glycol and/or glycerin mixture may consist of natural or artificial substances to provide it flavor. The cytotoxicity of e-liquids varies, and contamination with various chemicals have been detected in the liquid. Some liquids were very toxic and others had little or no cytotoxicity. The cytotoxicity is mostly due to the amount and number of flavors added. Since nicotine has a bitter taste, nicotine e-liquids contain chemicals to cover up the nicotine taste. The liquids contain aromatic substances like tobacco, fruit, vanilla, caramel and coffee. Generally, these additives are imprecisely described, using terms such as "vegetable flavoring". Although they are approved for human consumption there are no studies on the short-term or long-term effects of inhaling them. The safety of inhaling flavors is mostly unknown, and their safety has not been determined by the Flavor and Extract Manufacturers Association. In some cases e-liquids contain very large amounts of flavorings, which may cause irritation and inflammation on respiratory and cardiovascular systems. Some flavors are regarded as toxic and a number of them resemble known carcinogens. Some artificial flavors are known to be cytotoxic. Unflavored vapor is less cytotoxic than flavored vapor. A 2012 study demonstrated that in embryonic and adult cellular models, some substances of the vapor such as flavoring not found in tobacco smoke were cytotoxic.
Cinnamaldehyde has been described as a highly cytotoxic material in vitro in cinnamon-flavored refill liquids. Cinnamaldehyde have been identified as cytotoxic at the amount of about 400 times less than those allowed for use by the US Environmental Protection Agency. Some e-liquids containing cinnamaldehyde stimulate TRPA1, which might induce effects on the lung. E-liquids contain possibly toxic aldehydes and reactive oxygen species (ROS). Many flavors are known aldehydes, such as anisaldehyde, cinnamaldehyde, and isovaleraldehyde. The effects of aldehyde-containing flavors on pulmonary surfaces are unknown. A 2012 study found butterscotch flavor was highly toxic with one liquid and two others had a low toxicity. A 2014 in vitro study demonstrated that e-cigarette use of a "balsamic" flavor with no nicotine can activate the release of proinflammatory cytokine in lung epithelial cells and keratinocytes. Some additives may be added to reduce the irritation on the pharynx. The long-term toxicity is subject to the additives and contaminants in the e-liquid.
Certain flavorings contain diacetyl and acetyl propionyl which give a buttery taste. Diacetyl and acetyl propionyl are associated with bronchiolitis obliterans. A 2015 review recommended for specific regulation of diacetyl and acetyl propionyl in e-liquid, which are safe when ingested but have been associated with respiratory harm when inhaled. Both diacetyl and acetyl-propionyl have been found in concentrations above those recommended by the US National Institute for Occupational Safety and Health. Diacetyl is normally found at lower levels in e-cigarettes than in traditional cigarettes. Concerns exist that the flavors and additives in e-cigarettes might lead to diseases, including the popcorn lung. The cardiovascular effects, including a vast range of flavorings and fragrances, is unknown. The irritants butyl acetate, diethyl carbonate, benzoic acid, quinoline, bis(2-ethylhexyl) phthalate, and 2,6-dimethyl phenol were present as undeclared ingredients in the e-liquid. The precise ingredients of e-cigarettes are not known.
The IARC has categorized formaldehyde as a human carcinogen, and acetaldehyde is categorized as a potential carcinogenic to humans. Aldehydes may cause harmful health effects; though, in the majority of cases, the amounts inhaled are less than with traditional cigarettes. Many chemical compounds can inadvertently be produced from e-cigarettes, especially carbonyl compounds like formaldehyde, acetaldehyde, acrolein, and glyoxal by the chemical reaction of the e-liquid when the nichrome wire (heating element) is heated, to high temperatures. These compounds are frequently identified in e-cigarette aerosols. The propylene glycol-containing liquids produced the most amounts of carbonyls in e-cigarette aerosols. The levels of toxic chemicals in the vapor were found to be 1 to 2 orders of magnitude smaller than with cigarette smoke but greater than from a nicotine inhaler. Nearly all e-cigarettes evaluated, toxic and irritation-causing carbonyls were identified. Reports regarding the levels of toxic chemicals were inconsistent. This includes a study showing that the levels of toxicants in e-cigarettes may be higher than with cigarette smoke.
Battery output voltage influences the level of the carbonyl substances in the vapor. A few new e-cigarettes let users boost the amount of vapor and nicotine provided by modifying the battery output voltage. E-cigarettes with higher voltages (5.0 V) can emit carcinogens including formaldehyde at levels comparable to cigarette smoke, while reduced voltages (3.0 V) generate aerosol with levels of formaldehyde and acetaldehyde roughly 13 and 807-fold less than in cigarette smoke. "Dripping", where the liquid is dripped directly onto the atomizer, can create carbonyls including formaldehyde.
A 2015 PHE report found that normal e-cigarette use generates very low levels of aldehydes. Normal usage of e-cigarettes generates very low levels of formaldehyde, and at normal settings they generate very low levels of formaldehyde. Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[Notes 2] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage. A 2015 PHE report found 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 they concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes." However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.
Possible side effects of nicotine. A 2015 comparative risk analysis of drugs found the nicotine's margin of exposure (MOE) values were in a lower risk range than cocaine, heroine, and alcohol, whereas its MOE values was in a higher risk range than MDMA, methamphetamine, and methadone. Shown above is the MOE for daily drug use from the analysis.
Pregnant women, breastfeeding mothers, and the elderly are more sensitive to nicotine than other individuals. There are safety issues with the nicotine exposure from e-cigarettes, which may cause addiction and other adverse effects. Nicotine is regarded as a potentially lethal poison. Concerns exist that vaping can be harmful by exposing users to toxic levels of nicotine. At low amounts, it has a mild analgesic effect. At high enough doses, nicotine may result in nausea, vomiting, diarrhea, salivation, bradyarrhythmia, and possibly seizures and hypoventilation. However, at the low amount of nicotine provided by e-cigarettes fatal overdose from use is unlikely; in contrast, the potent amount of nicotine in e-cigarettes liquids may be toxic if it is accidentally ingested or absorbed via the skin. The health effects of nicotine in infants and children are unclear.
E-cigarettes provide nicotine to the blood quicker than nicotine inhalers. The levels were above that of nicotine replacement product users. E-cigarettes seem to have a pharmacokinetic nicotine profile closer to nicotine replacement products than with traditional cigarettes. How efficiently different e-cigarettes give nicotine is unclear.Serum cotinine levels are comparable to that of traditional cigarettes, but are inharmonious and rely upon the user and the device. Blood nicotine levels raised more gradually and took more time to get to peak concentration with e-cigarettes than with traditional cigarettes.
When compared to traditional cigarettes older devices usually delivered low amounts of nicotine. E-cigarette use can be associated with a substantial dispersion of nicotine, thus generating a plasma nicotine concentration which can be comparable to that of traditional cigarettes. This is due to the minute nicotine particles in the vapor, which permit quick delivery into the bloodstream. The nicotine delivered from e-cigarettes enters the body slower than traditional cigarettes. Studies suggest that inexperienced users obtain moderate amounts of nicotine from e-cigarettes. Concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device.
Later-generation e-cigarettes gives nicotine more effectively than first-generation e-cigarettes. Later-generation models with concentrated nicotine liquids may deliver nicotine at levels similar to traditional cigarettes. E-cigarettes with stronger batteries heat solutions to higher temperatures, which may raise blood nicotine levels to those of traditional cigarettes. Research suggests that experienced e-cigarettes users are able to get as much nicotine from e-cigarettes as traditional cigarettes. Later-generation e-cigarettes containing sufficient nicotine elevates heart rate comparable to traditional cigarettes.
The health effects of long-term nicotine use is unknown. It may be decades before the long-term health effects of nicotine vapor inhalation is known. It is not recommended for non-smokers. Nicotine affects practically every cell in the body. Nicotine can cause high blood pressure and abnormal heart rhythms. Vapers that get a higher amount of blood nicotine are probably correlated with increased heart rates. Nicotine may have adverse effects on lipids, cause insulin resistance. and can lower coronary blood flow. Nicotine lowers estrogen levels and has been associated with early menopause in women. Nicotine could have cancer-promoting properties, therefore long-term use may not be harmless. Nicotine may result in neuroplasticity variations in the brain. Nicotine could make cancer therapies less effective.
Children are more sensitive to nicotine than adults. In youth, nicotine may affect capabilities connected with higher cognitive function processes, later achievement, as well as the chance of nicotine addiction for life. The adolescents developing brain is especially sensitive to the harmful effects of nicotine. A short period of regular or occasional nicotine exposure in adolescence exerts long-term neurobehavioral damage. In August 2014, the American Heart Association noted that "e-cigarettes could fuel and promote nicotine addiction, especially in children." A policy statement by the UK's Faculty of Public Health has stated, "A key concern for everyone in public health is that children and young people are being targeted by mass advertising of e-cigarettes. There is a danger that e-cigarettes will lead to young people and non-smokers becoming addicted to nicotine and smoking. Evidence from the US backs up this concern."
There is limited evidence on the long-term exposure of metals. Exposure to the levels and kinds of metals found in the aerosol relies upon the material and other manufacturing designs of the heating element. E-cigarettes contain some contamination with small amounts of metals in the emissions but it is not likely that these amounts would cause a serious risk to the health of the user. The device itself could contribute to the toxicity from the tiny amounts of silicate and heavy metals found in the liquid and vapor, because they have metal parts that come in contact with the e-liquid. Low levels of possibly harmful chromium, lead, and nickel metals have been found in the emissions. Chromium and nickel nanoparticles have also been found.
Metals may adversely affect the nervous system. A 2013 review found metallic and nanoparticles are associated with respiratory distress and disease. A 2014 review found considerable amounts of tin, metals, and silicate particles that came from various components of the e-cigarette were released into the aerosol, which result in exposure that could be higher than with cigarette smoke. A 2013 study found metal particles in the aerosol were at levels 10-50 times less than permitted in inhalation medicines. A 2014 review suggested that there is no evidence of contamination of the aerosol with metals that justifies a health concern.
Abbreviations: μg, microgram; ng, nanogram; ND, not detected.
∗Fifteen puffs were chosen to estimate the nicotine delivery of one traditional cigarette.
The risks to the lungs are not fully understood, and concern exists regarding the negative effects on lung function. There is limited evidence on the long-term health effects to the lungs. Many ingredients used in e-liquids have not been examined in the lung. The effects of e-cigarette use in respect to asthma and other respiratory diseases are unknown. A 2015 review found e-cigarettes may induce acute lung disease. A 2015 study found that e-cigarette vapors can induce oxidative stress in lung endothelial cells. Constant lung inflammation as a result of the vapor could result in lung pathogenesis and induce serious diseases, including chronic obstructive pulmonary disease and fibrosis. The limited evidence suggests that e-cigarettes produce less short-term effects on lung function than traditional cigarettes. A 2014 case report observed the correlation between sub-acute bronchiolitis and vaping. After quitting vaping the symptoms improved.
The long-term effects regarding respiratory flow resistance are unknown. E-cigarettes could harm the respiratory system. The immediate effects of e-cigarettes after 5 minutes of use on pulmonary function resulted in considerable increases in resistance to lung airflow. A 2013 review found an instant increase in airway resistance after using a single e-cigarette. Any reported harmful effects to cardiovascular and respiratory functions after short-term use of e-cigarettes were appreciably milder in comparison to cigarette smoke. When used in the short-term, an e-cigarette resulted in a rise of respiratory resistance comparatively to traditional cigarettes. E-cigarette use could result in respiratory diseases among youth.
There is no data available on the long-term cardiovascular effects. There is no published research available on vaping and thrombosis, platelet reactivity, atherosclerosis, or blood vessel function. The minute nicotine particles in the vapor could increase the risk of cardiac arrhythmias and hypertension which may put some users, particularly those with atherosclerosis or other cardiovascular risk factors, at significant risk of acute coronary syndrome. Some case reports documented the possible cardiovascular adverse effects from using e-cigarettes, the majority associated was with improper use. Even though e-cigarettes are anticipated to produce fewer harmful substances than traditional cigarettes, limited evidence supports they comparatively have a lessened raised cardiovascular risk. E-cigarette use leads to sympathomimetic effects because of nicotine intake. It is argued that there could be a risk for harmful effects, including tachycardia-induced cardiomyopathy. E-cigarettes containing nicotine may have a lower cardiovascular effect than traditional cigarettes containing nicotine. Short-term physiological effects include increases in blood pressure and heart rate. A 2012 case report found a correlation between paroxysmal atrial fibrillation and vaping.
Comparable to a traditional cigarette, e-cigarette particles are tiny enough to enter the alveoli, enabling nicotine absorption. These particles are also tiny enough to go deep in the lungs and enter into the systemic circulation. Local pulmonary toxicity may occur because metal nanoparticles can deposit in the lung's alveolar sacs. E-cigarettes companies assert that the particulates produced by an e-cigarette are too tiny to be deposited in the alveoli. Different devices generate different particle sizes and cause different depositions in the respiratory tract, even from the same nicotine liquid. The aerosol production of e-cigarettes during vaping decreases, which requires a more forceful suction to create a similar volume of aerosol. A more forceful suction could affect the deposition of substances into the lungs. Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern.
Concern exists regarding the immunological effects of e-liquid, and analysis on animals demonstrate that e-liquid vapor, appear to have adverse effects on the immune system. There were reports of e-cigarettes causing an immune system reaction involving inflammation of the gastrointestinal system. Long-term use could increase the risk of tuberculosis. It is possible that e-cigarettes could harm the periodontium because of the effects of nicotine on gum tissues and the immune system. Some health effects associated with e-cigarette use can include recurring ulcerative colitis, lipoid pneumonia, acute eosinophilic pneumonitis, sub-acute bronchial toxicity, reversible cerebral vasoconstriction syndrome, and reversal of chronic idiopathic neutrophilia.
Aerosol (vapor) exhaled by an e-cigarette user.
The aerosol of e-cigarettes is generated when the e-liquid reaches a temperature of roughly 100-250 °C within a chamber. The user inhales the aerosol, commonly called vapor, rather than cigarette smoke. In physics, a vapor is a substance in the gas phase whereas an aerosol is a suspension of tiny particles of liquid, solid or both within a gas. The aerosol is made-up of liquid sub-micron particles of condensed vapor, which mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and other chemicals. After a puff, inhalation of the aerosol travels from the device into the mouth and lungs. The particle size distribution and sum of particles emitted by e-cigarettes are like traditional cigarettes, with the majority of particles in the ultrafine range.
Various bottles of e-liquid.
After the aerosol is inhaled, it is exhaled. Emissions from electronic cigarettes are not comparable to environmental pollution or cigarette smoke as their nature and chemical composition are completely different The particles are larger, with the mean size being 600 nm in inhaled aerosol and 300 nm in exhaled vapor. Bystanders are exposed to these particles from exhaled e-cigarette vapor. There is a concern that some of the mainstream vapor exhaled by e-cigarette users can be inhaled by bystanders, particularly indoors, and have significant adverse effects. Since e-cigarettes involve an aerosolization process, it is suggested that no meaningful amounts of carbon monoxide are emitted. Thus, cardiocirculatory effects caused by carbon monoxide are not likely. E-cigarette use by a parent might lead to inadvertent health risks to offspring. E-cigarettes pose many safety concerns to children. For example, indoor surfaces can accumulate nicotine where e-cigarettes were used, which may be inhaled by children, particularly youngsters, long after they were used.
E-liquid is the mixture used in vapor products such as electronic cigarettes. The main ingredients in the e-liquid usually are propylene glycol, glycerin, nicotine, and flavorings. However, there are e-liquids sold without propylene glycol, nicotine, or flavors. The liquid typically contains 95% propylene glycol and glycerin. The flavorings may be natural or artificial. About 8,000 flavors exist as of 2014. There are many e-liquids manufacturers in the USA and worldwide. While there are currently no US Food and Drug Administration (FDA) manufacturing standards for e-liquid, the FDA has proposed regulations that are expected to be finalized in late 2015. Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).
Concerns exists regarding pregnant women exposure to e-cigarette vapor through direct use or via exhaled vapor. No evidence have shown that e-cigarettes are safe to use for pregnant women. No amount of nicotine is safe for pregnant women. As of 2014[update], there are no conclusions on the possible hazards of pregnant women using e-cigarettes, and there is a developing research on the negative effects of nicotine on prenatal brain development. E-cigarette are assumed to be dangerous to the fetus during pregnancy if e-cigarettes are used by the mother. Nicotine is harmful to the growing fetus. Nicotine accumulates in the fetus because it goes through the placenta.
As of 2015[update], the long-term issues of e-cigarettes on both mother and unborn baby are unknown. Prenatal nicotine exposure is associated with adverse effects on the growing fetus, including effects to normal growth of the endocrine, reproductive, respiratory, cardiovascular, and neurologic systems. Prenatal nicotine exposure is associated with lower birth weights than other babies,stillbirth,sudden infant death syndrome, and alterations to normal brain development. Prenatal nicotine exposure is associated with asthma and wheezing which may continue into adulthood.Gestational age nicotine exposure is associated with many neurological deficits. Prenatal exposure has been associated with obesity, diabetes, high cholesterol and high blood pressure in minors. Prenatal nicotine exposure in females may lead toward early menarche. An infant was born with necrotizing enterocolitis due to e-cigarette use during pregnancy.
In what way the e-liquid ingredients could affect a fetus is unknown. The toxicity of e-liquid flavorings was higher in embryonic stem cells compared to differentiated adult pulmonary fibroblasts, leading to concerns about pregnant women being exposed to the second-hand vapor. There are concerns about the health impacts of pediatric exposure to second-hand and third-hand e-cigarette vapor. The Surgeon General's 2014 report found "that nicotine adversely affects maternal and fetal health during pregnancy, and that exposure to nicotine during fetal development has lasting adverse consequences for brain development." The belief that e-cigarettes are safer than traditional cigarettes could increase their use in pregnant women. The toxic effects identified with e-cigarette refill liquids on stem cells may be interpreted as embryonic death or birth defects. Since e-cigarettes are not validated as cessation tools, may contain nicotine at inconsistent levels and added ingredients that are possibly harmful, allowing e-cigarettes to be used among pregnant women to decrease smoking puts this group at considerable risk. There is concern for breastfeeding women using e-cigarettes, due to the lack of data on propylene glycol transferring to breastmilk.
There is limited information available on any environmental issues connected to the production, usage, and disposal of e-cigarette models that use cartridges. As of 2014[update], no formal studies have been done to evaluate the environmental effects of making or disposing of any part of e-cigarettes including the batteries or nicotine production. As of 2014[update], it is uncertain if the nicotine in e-liquid is United States Pharmacopeia-grade nicotine, a tobacco extract, or synthetic nicotine when questioning the environmental impact of how it is made. It is not clear which manufacturing methods are used to make the nicotine used in e-cigarettes. The emissions from making nicotine could be considerable from manufacturing if not appropriately controlled. Some e-cigarette brands that use cartridges state their products are ‘eco-friendly’ or ‘green’, despite the absence of any supporting studies. Some writers contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors.
It is unclear how many traditional cigarettes are comparable to using one e-cigarette that uses a cartridge for the average user. Information is limited on energy and materials used for production of e-cigarettes versus traditional cigarettes, for comparable use. E-cigarettes can be made manually put together in small factories, or they can be made in automated lines on a much bigger scale. Larger plants will produce greater emissions to the surrounding environment, and thus will have a greater environmental impact. Although some brands have begun recycling services for their e-cigarette cartridges and batteries, the prevalence of recycling is unknown, as is the prevalence of information provided by manufacturers on how to recycle disposable parts. A 2014 review found "disposable e-cigarettes might cause an electrical waste problem." Since the majority of e-cigarettes are reusable they are possibly more environmentally friendly than using single-use devices. Compared to traditional cigarettes, e-cigarettes do not create litter in the form of discarded cigarette butts. Traditional cigarette tend to end up in the ocean where they cause pollution.
Marketing and advertisement affects the public’s perception of e-cigarettes. Some tobacco users think vaping is safer than tobacco or other smoking cessation aids. It is generally considered by users that e-cigarettes are safer than tobacco. Many users think that e-cigarettes are healthier than traditional cigarettes for personal use or for other people. Usually, only a small proportion of users are concerned about the possible adverse health effects or toxicity of e-cigarettes. A 2014 worldwide survey found that 88% of respondents stated that vaping were less harmful than cigarette smoke and 11% believed that vaping were absolutely harmless. A 2013 four-country survey found higher than 75% of current and former smokers think e-cigarettes are safer than traditional cigarettes. The UK Action on Smoking and Health (ASH) found that in 2015, compared to the year before, "there has been a growing false belief that electronic cigarettes could be as harmful as smoking". Among smokers who had heard of e-cigarettes but never tried them, this "perception of harm has nearly doubled from 12% in 2014 to 22% in 2015." The UK ASH expressed concern that "The growth of this false perception risks discouraging many smokers from using electronic cigarettes to quit and keep them smoking instead which would be bad for their health and the health of those around them."
A 2015 PHE report noted that in the US belief among respondents to a survey that vaping was safer than smoking cigarettes fell from 82% in 2010 to 51% in 2014. The report blamed "misinterpreted research findings", attracting negative media coverage, for the growth in the "inaccurate" belief that e-cigarettes were as harmful as smoking,and concluded that "There is a need to publicise the current best estimate that using EC is around 95% safer than smoking".[duplication?]
- ^ a b c d e f g h i j k l m n 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. doi:10.1016/j.mayocp.2014.11.004. ISSN 0025-6196. PMID 25572196.
- ^ a b Siu, AL (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. doi:10.7326/M15-2023. PMID 26389730.
- ^ a b Harrell, PT; Simmons, VN; Correa, JB; Padhya, TA; Brandon, TH (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. doi:10.1177/0194599814536847. PMC 4376316 . PMID 24898072.
- ^ a b Patnode, Carrie D.; Henderson, Jillian T.; Thompson, Jamie H.; Senger, Caitlyn A.; Fortmann, Stephen P.; Whitlock, Evelyn P. (September 2015). "Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force" (PDF). Annals of Internal Medicine. 163 (8): 15. doi:10.7326/M15-0171. ISSN 0003-4819. PMID 26491759.
- ^ a b c d e f g h i j k l m n o p q r s t u v Grana, R; Benowitz, N; Glantz, SA (13 May 2014). "E-cigarettes: a scientific review.". Circulation. 129 (19): 1972–86. doi:10.1161/circulationaha.114.007667. PMC 4018182 . PMID 24821826.
- ^ a b c Farsalinos, Konstantinos; LeHouezec, Jacques (2015). "Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)". Risk Management and Healthcare Policy. 8: 157–67. doi:10.2147/RMHP.S62116. ISSN 1179-1594. PMC 4598199 . PMID 26457058.
- ^ a b c "Electronic nicotine delivery systems" (PDF). WHO. pp. 1–13. Retrieved 28 August 2014.
- ^ a b c d e f g h Drummond, MB; Upson, D (February 2014). "Electronic cigarettes. Potential harms and benefits.". Annals of the American Thoracic Society. 11 (2): 236–42. doi:10.1513/annalsats.201311-391fr. PMID 24575993.
- ^ a b c d e f g h i j k l m n o p q r s 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. doi:10.1177/2042098614524430. ISSN 2042-0986. PMC 4110871 . PMID 25083263.
- ^ a b Knorst, Marli Maria; Benedetto, Igor Gorski; Hoffmeister, Mariana Costa; Gazzana, Marcelo Basso (2014). "The electronic cigarette: the new cigarette of the 21st century?". Jornal Brasileiro de Pneumologia. 40 (5): 564–572. doi:10.1590/S1806-37132014000500013. ISSN 1806-3713. PMC 4263338 . PMID 25410845.
- ^ a b c "The Potential Adverse Health Consequences of Exposure to Electronic Cigarettes and Electronic Nicotine Delivery Systems". Oncology Nursing Forum. 42 (5): 445–446. 2015. doi:10.1188/15.ONF.445-446. ISSN 0190-535X. PMID 26302273.
- ^ a b c d e Pisinger, Charlotta; Døssing, Martin (December 2014). "A systematic review of health effects of electronic cigarettes". Preventive Medicine. 69: 248–260. doi:10.1016/j.ypmed.2014.10.009. PMID 25456810.
- ^ a b c d e f g h i j k l m n Hajek, P; Etter, JF; 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. doi:10.1111/add.12659. PMC 4487785 . PMID 25078252.
- ^ a b c d e f g h i j k l 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. doi:10.1016/j.amjmed.2015.01.033. ISSN 0002-9343. PMID 25731134.
- ^ a b 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. doi:10.1186/1617-9625-12-21. PMC 4350653 . PMID 25745382. CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h Breland, Alison B.; Spindle, Tory; Weaver, Michael; Eissenberg, Thomas (2014). "Science and Electronic Cigarettes". Journal of Addiction Medicine. 8 (4): 223–233. doi:10.1097/ADM.0000000000000049. ISSN 1932-0620. PMC 4122311 . PMID 25089952.
- ^ a b c d e f g h i j k l m n o 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. doi:10.1158/1078-0432.CCR-14-2544. ISSN 1078-0432. PMID 25573384.
- ^ a b c d e f g h i Durmowicz, E. L. (2014). "The impact of electronic cigarettes on the paediatric population". Tobacco Control. 23 (Supplement 2): ii41–ii46. doi:10.1136/tobaccocontrol-2013-051468. ISSN 0964-4563. PMC 3995262 . PMID 24732163.
- ^ a b c d e f g h i j k l m n o 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. doi:10.1152/ajplung.00272.2015. ISSN 1040-0605. PMC 4683316 . PMID 26408554.
- ^ a b c d e f g h 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. doi:10.1016/j.jaip.2015.05.022. ISSN 2213-2198. PMID 26164573.
- ^ a b c d e f g h i j k l m n o p q Bertholon, J.F.; Becquemin, M.H.; Annesi-Maesano, I.; Dautzenberg, B. (2013). "Electronic Cigarettes: A Short Review". Respiration. 86: 433–8. doi:10.1159/000353253. ISSN 1423-0356. PMID 24080743.
- ^ a b c d e f g h i j k Bekki, Kanae; Uchiyama, Shigehisa; Ohta, Kazushi; Inaba, Yohei; Nakagome, Hideki; Kunugita, Naoki (2014). "Carbonyl Compounds Generated from Electronic Cigarettes". International Journal of Environmental Research and Public Health. 11 (11): 11192–11200. doi:10.3390/ijerph111111192. ISSN 1660-4601. PMC 4245608 . PMID 25353061.
- ^ a b c Wilder 2016, p. 82.
- ^ a b c d e f g h i j k l m Cheng, T. (2014). "Chemical evaluation of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii11–ii17. doi:10.1136/tobaccocontrol-2013-051482. ISSN 0964-4563. PMC 3995255 . PMID 24732157.
- ^ 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.
- ^ a b c d McNeill 2015, p. 77.
- ^ a b McNeill 2015, p. 77-78.
- ^ a b c d e Jerry JM, Collins GB, Streem D (2015). "E-cigarettes: Safe to recommend to patients?". Cleve Clin J Med. 82 (8): 521–6. doi:10.3949/ccjm.82a.14054. PMID 26270431. CS1 maint: Uses authors parameter (link)
- ^ a b c d "The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, Chapter 5 - Nicotine" (PDF). Surgeon General of the United States. 2014. pp. 107–138. PMID 24455788.
- ^ Goniewicz, ML; Knysak, J; Gawron, M; Kosmider, L; Sobczak, A; Kurek, J; Prokopowicz, A; Jablonska-Czapla, M; Rosik-Dulewska, C; Havel, C; Jacob P, 3rd; Benowitz, N (March 2014). "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes.". Tobacco control. 23 (2): 133–9. doi:10.1136/tobaccocontrol-2012-050859. PMC 4154473 . PMID 23467656.
- ^ a b c d e f 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. doi:10.1016/j.jadohealth.2015.07.020. ISSN 1054-139X. PMID 26422289.
- ^ Fernández, Esteve; Ballbè, Montse; Sureda, Xisca; Fu, Marcela; Saltó, Esteve; Martínez-Sánchez, Jose M. (2015). "Particulate Matter from Electronic Cigarettes and Conventional Cigarettes: a Systematic Review and Observational Study". Current Environmental Health Reports. 2: 423–9. doi:10.1007/s40572-015-0072-x. ISSN 2196-5412. PMID 26452675.
- ^ a b c Burstyn, Igor (9 January 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. doi:10.1186/1471-2458-14-18. ISSN 1471-2458. PMC 3937158 . PMID 24406205.
- ^ a b c d e f g h i j k l m n o p 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. doi:10.1111/nyas.12609. ISSN 0077-8923. PMID 25557889.
- ^ a b c d e f g h 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. doi:10.1016/j.amepre.2015.01.015. ISSN 0749-3797. PMC 4594223 . PMID 25794473.
- ^ 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. doi:10.1177/2040622314521271. PMC 3926346 . PMID 24587890.
- ^ a b c d e f g h i j k l m Chang, H. (2014). "Research gaps related to the environmental impacts of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii54–ii58. doi:10.1136/tobaccocontrol-2013-051480. ISSN 0964-4563. PMC 3995274 . PMID 24732165.
- ^ a b c d e f "Electronic Cigarettes – An Overview" (PDF). German Cancer Research Center. 2013.
- ^ Bush, Ashley M.; Holsinger, James W.; Prybil, Lawrence D. (2016). "Employing the Precautionary Principle to Evaluate the Use of E-Cigarettes". Frontiers in Public Health. 4. doi:10.3389/fpubh.2016.00005. ISSN 2296-2565. PMC 4740382 . PMID 26870723.
- ^ a b c d e f g h i j 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. doi:10.1161/CIR.0000000000000107. PMID 25156991.
- ^ a b c d e f g h i j k l Hua, My; Talbot, Prue (2016). "Potential health effects of electronic cigarettes: A systematic review of case reports". Preventive Medicine Reports. 4: 169–178. doi:10.1016/j.pmedr.2016.06.002. ISSN 2211-3355. PMC 4929082 . PMID 27413679.
- ^ "E-Cigarettes". Tobacco Control Research Branch of the National Cancer Institute.
- ^ "Stop smoking treatments". UK National Health Service. 25 July 2014.
- ^ "Standards of Medical Care in Diabetes--2015: Summary of Revisions". Diabetes Care. 54 (38): S25. 2015. doi:10.2337/dc15-S003. PMID 25537706.
- ^ &NA; (August 2014). "E-Cigarettes". Oncology Times. 36 (15): 49–50. doi:10.1097/01.COT.0000453432.31465.77.
- ^ "Nicotine addiction". Health Canada. 7 March 2013.
- ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016.
- ^ Detailed reference list is located at a separate image page.
- ^ McNeill 2015, p. 76.
- ^ The Lancet (August 2015). "E-cigarettes: Public Health England's evidence-based confusion". The Lancet. 386 (9996): 829. doi:10.1016/S0140-6736(15)00042-2.
- ^ "RCP statement on e-cigarettes". Royal College of Physicians. 25 June 2014.
- ^ a b c d e 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. doi:10.1002/lary.24750. PMID 25302452.
- ^ a b c d e Dagaonkar RS, R.S.; Udwadi, Z.F. (2014). "Water pipes and E-cigarettes: new faces of an ancient enemy" (PDF). Journal of the Association of Physicians of India. 62 (4): 324–328. PMID 25327035.
- ^ "What about electronic cigarettes? Aren’t they safe?". American Cancer Society.
- ^ "Ways to quit". Canadian Cancer Society. 2016.
- ^ "Nicotine products can help people to cut down before quitting smoking". National Institute for Health and Care Excellence. June 2013.
- ^ "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original (PDF) on 6 November 2014.
- ^ a b c d e 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. doi:10.1136/tobaccocontrol-2013-051122. ISSN 0964-4563. PMC 4520227 . PMID 24259045.
- ^ Detailed reference list is located at a separate image page.
- ^ a b c d e Gualano, Maria Rosaria; Passi, Stefano; Bert, Fabrizio; La Torre, Giuseppe; Scaioli, Giacomo; Siliquini, Roberta (2015). "Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies". Journal of Public Health. 37 (3): 488–497. doi:10.1093/pubmed/fdu055. ISSN 1741-3842. PMID 25108741.
- ^ a b McRobbie, Hayden; Bullen, Chris; Hartmann-Boyce, Jamie; Hajek, Peter; McRobbie, Hayden (2014). "Electronic cigarettes for smoking cessation and reduction". The Cochrane Library. 12: CD010216. doi:10.1002/14651858.CD010216.pub2. PMID 25515689.
- ^ 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)
- ^ Bullen, Christopher (2014). "Electronic Cigarettes for Smoking Cessation". Current Cardiology Reports. 16 (11): 538. doi:10.1007/s11886-014-0538-8. ISSN 1523-3782. PMID 25303892.
- ^ a b c Smith, L; Brar, K; Srinivasan, K; Enja, M; Lippmann, S (June 2016). "E-cigarettes: How "safe" are they?". The Journal of Family Practice. 65 (6): 380–385. PMID 27474819.
- ^ 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. doi:10.2174/1874473707666141015220110. ISSN 1874-4737. PMC 4469045 . PMID 25323124.
- ^ a b c Evans, S. E.; Hoffman, A. C. (2014). "Electronic cigarettes: abuse liability, topography and subjective effects". Tobacco Control. 23 (Supplement 2): ii23–ii29. doi:10.1136/tobaccocontrol-2013-051489. ISSN 0964-4563. PMC 3995256 . PMID 24732159.
- ^ a b Orr, KK; Asal, NJ (November 2014). "Efficacy of Electronic Cigarettes for Smoking Cessation.". The Annals of pharmacotherapy. 48 (11): 1502–1506. doi:10.1177/1060028014547076. PMID 25136064.
- ^ Detailed reference list is located at a separate image page.
- ^ a b c Kaisar, Mohammad Abul; Prasad, Shikha; Liles, Tylor; Cucullo, Luca (2016). "A Decade of e-Cigarettes: Limited Research & Unresolved Safety Concerns". Toxicology. 365: 67–75. doi:10.1016/j.tox.2016.07.020. ISSN 0300-483X. PMID 27477296.
- ^ 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. doi:10.7326/M14-2481. ISSN 0003-4819. PMID 25894027.
- ^ a b Biyani, S; Derkay, CS (28 April 2015). "E-cigarettes: Considerations for the otolaryngologist.". International journal of pediatric otorhinolaryngology. 79: 1180–3. doi:10.1016/j.ijporl.2015.04.032. PMID 25998217.
- ^ a b McNeill 2015, p. 63.
- ^ Chatham-Stephens K, Law R, Taylor E, Melstrom P, Bunnell R, Wang B, Apelberg B, Schier JG (April 2014). "Notes from the field: calls to poison centers for exposures to electronic cigarettes--United States, September 2010-February 2014". MMWR Morb. Mortal. Wkly. Rep. Centers for Disease Control and Prevention (CDC). 63 (13): 292–3. PMID 24699766. CS1 maint: Multiple names: authors list (link)
- ^ a b c d e f g h i j k l m n o p q r Chatham-Stephens, Kevin; Law, Royal; Taylor, Ethel; Kieszak, Stephanie; Melstrom, Paul; Bunnell, Rebecca; Wang, Baoguang; Day, Hannah; Apelberg, Benjamin; Cantrell, Lee; Foster, Howell; Schier, Joshua G. (June 2016). "Exposure Calls to U. S. Poison Centers Involving Electronic Cigarettes and Conventional Cigarettes—September 2010–December 2014". Journal of Medical Toxicology. 12: 350–357. doi:10.1007/s13181-016-0563-7. ISSN 1556-9039. PMID 27352081.
- ^ a b c d Nelluri, Bhargava Krishna; Murphy, Katie; Mookadam, Farouk (2015). "Electronic cigarettes and cardiovascular risk: hype or up in smoke?". Future Cardiology. 11 (3): 271–273. doi:10.2217/fca.15.13. ISSN 1479-6678. PMID 26021631.
- ^ a b Kamboj, A.; Spiller, H. A.; Casavant, M. J.; Chounthirath, T.; Smith, G. A. (2016). "Pediatric Exposure to E-Cigarettes, Nicotine, and Tobacco Products in the United States". Pediatrics. 137 (6): e20160041–e20160041. doi:10.1542/peds.2016-0041. ISSN 0031-4005. PMID 27244861.
- ^ "Poison Center Calls Involving E-Cigarettes". CDC. 14 April 2016.
- ^ "Electronic Cigarettes and Liquid Nicotine Data" (PDF). American Association of Poison Control Centers. Retrieved 9 January 2016.
- ^ a b Yang, L.; Rudy, S. F.; Cheng, J. M.; Durmowicz, E. L. (2014). "Electronic cigarettes: incorporating human factors engineering into risk assessments". Tobacco Control. 23 (Supplement 2): ii47–ii53. doi:10.1136/tobaccocontrol-2013-051479. ISSN 0964-4563. PMC 3995290 . PMID 24732164.
- ^ a b SA, Meo; SA, Al Asiri (2014). "Effects of electronic cigarette smoking on human health" (PDF). Eur Rev Med Pharmacol Sci. 18 (21): 3315–9. PMID 25487945.
- ^ a b c Brown, C. J.; Cheng, J. M. (2014). "Electronic cigarettes: product characterisation and design considerations". Tobacco Control. 23 (Supplement 2): ii4–ii10. doi:10.1136/tobaccocontrol-2013-051476. ISSN 0964-4563. PMC 3995271 . PMID 24732162.
- ^ a b c d "State Health Officer’s Report on E-Cigarettes: A Community Health Threat" (PDF). California Department of Public Health, California Tobacco Control Program. January 2015.
- ^ a b Frey, Leslie T.; Tilburg, William C. (2016). "Child-Resistant Packaging for E-Liquid: A Review of US State Legislation". American Journal of Public Health. 106 (2): 266–268. doi:10.2105/AJPH.2015.302957. ISSN 0090-0036. PMID 26691114.
- ^ a b c d e 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. doi:10.1016/j.arbres.2014.02.006. PMID 24684764.
- ^ McKee, M. (2014). "Electronic cigarettes: peering through the smokescreen" (PDF). Postgraduate Medical Journal. 90 (1069): 607–609. doi:10.1136/postgradmedj-2014-133029. ISSN 0032-5473. PMID 25294933.
- ^ Mayer, Bernd (January 2014). "How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century". Archives of Toxicology. 88 (1): 5–7. doi:10.1007/s00204-013-1127-0. ISSN 0340-5761. PMC 3880486 . PMID 24091634.
- ^ a b c d Breland, Alison; Soule, Eric; Lopez, Alexa; Ramôa, Carolina; El-Hellani, Ahmad; Eissenberg, Thomas (2016). "Electronic cigarettes: what are they and what do they do?". Annals of the New York Academy of Sciences: n/a–n/a. doi:10.1111/nyas.12977. ISSN 0077-8923. PMC 4947026 . PMID 26774031.
- ^ Eggleston, William; Nacca, Nicholas; Stork, Christine M.; Marraffa, Jeanna M. (2016). "Pediatric death after unintentional exposure to liquid nicotine for an electronic cigarette". Clinical Toxicology. 54: 1–2. doi:10.1080/15563650.2016.1207081. ISSN 1556-3650. PMID 27383772.
- ^ "E-Cigarette Poisonings Among Toddlers Skyrocketed 1500% Over 3 Years". Yahoo! News. 9 May 2016.
- ^ a b McNeill 2015, p. 67–68.
- ^ "Electronic cigarettes". Therapeutic Goods Administration.
- ^ a b c Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. doi:10.3390/ijerph120809988. ISSN 1660-4601. PMC 4555324 . PMID 26308021.
- ^ a b c d e f g h i j Paley, Grace L.; Echalier, Elizabeth; Eck, Thomas W.; Hong, Augustine R.; Farooq, Asim V.; Gregory, Darren G.; Lubniewski, Anthony J. (2016). "Corneoscleral Laceration and Ocular Burns Caused by Electronic Cigarette Explosions". Cornea. 35 (7): 1015–1018. doi:10.1097/ICO.0000000000000881. ISSN 0277-3740. PMC 4900417 . PMID 27191672.
- ^ a b c d Bart Jansen (23 January 2015). "Packing e-Cigarettes in luggage is a fire risk, FAA warns". USA Today.
- ^ McNeill 2015, p. 43-46.
- ^ McNeill 2015, p. 83-84.
- ^ a b Ashley Hasley III (26 January 2015). "The FAA wants you to carry on your e-Cigs". The Washington Post.
- ^ a b c d e f g h Weaver, Michael; Breland, Alison; Spindle, Tory; Eissenberg, Thomas (2014). "Electronic Cigarettes". Journal of Addiction Medicine. 8 (4): 234–240. doi:10.1097/ADM.0000000000000043. ISSN 1932-0620. PMC 4123220 . PMID 25089953.
- ^ a b "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). Cancer Research UK. May 2014.
- ^ a b Orr, M. S. (2014). "Electronic cigarettes in the USA: a summary of available toxicology data and suggestions for the future". Tobacco Control. 23 (Supplement 2): ii18–ii22. doi:10.1136/tobaccocontrol-2013-051474. ISSN 0964-4563. PMC 3995288 . PMID 24732158.
- ^ a b Caponnetto, P.; Russo, C.; Bruno, C.M.; Alamo, A.; Amaradio, M.D.; Polosa, R. (March 2013). "Electronic cigarette: a possible substitute for cigarette dependence". Monaldi Archives for Chest Disease. 79 (1): 12–19. doi:10.4081/monaldi.2013.104. ISSN 1122-0643. PMID 23741941.
- ^ Wilder 2016, p. 87.
- ^ "E-cigarettes to be regulated as medicines". National Health Service. 12 June 2013. Retrieved 1 August 2013.
- ^ "WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems". World Medical Association.
- ^ Arnold, Carrie (2014). "Vaping and Health: What Do We Know about E-Cigarettes?". Environmental Health Perspectives. 122 (9): A244–A249. doi:10.1289/ehp.122-A244. PMC 4154203 . PMID 25181730.
- ^ 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. doi:10.1057/jphp.2010.41. PMID 21150942.
- ^ a b c d e "WHO Right to Call for E-Cigarette Regulation". World Lung Federation.
- ^ Alawsi, F.; Nour, R.; Prabhu, S. (2015). "Are e-cigarettes a gateway to smoking or a pathway to quitting?". BDJ. 219 (3): 111–115. doi:10.1038/sj.bdj.2015.591. ISSN 0007-0610. PMID 26271862.
- ^ a b c d Franck, Caroline; Filion, Kristian B.; Kimmelman, Jonathan; Grad, Roland; Eisenberg, Mark J. (2016). "Ethical considerations of e-cigarette use for tobacco harm reduction". Respiratory Research. 17 (1). doi:10.1186/s12931-016-0370-3. ISSN 1465-993X. PMC 4869264 . PMID 27184265.
- ^ a b c d e Schraufnagel DE (2015). "Electronic Cigarettes: Vulnerability of Youth". Pediatr Allergy Immunol Pulmonol. 28 (1): 2–6. doi:10.1089/ped.2015.0490. PMC 4359356 . PMID 25830075. CS1 maint: Uses authors parameter (link)
- ^ Naik, Pooja; Cucullo, Luca (2015). "Pathobiology of tobacco smoking and neurovascular disorders: untied strings and alternative products". Fluids and Barriers of the CNS. 12 (1). doi:10.1186/s12987-015-0022-x. ISSN 2045-8118. PMC 4628383 . PMID 26520792.
- ^ Bhatnagar, Aruni (2016). "Cardiovascular Perspective of the Promises and Perils of E-Cigarettes". Circulation Research. 118 (12): 1872–1875. doi:10.1161/CIRCRESAHA.116.308723. ISSN 0009-7330. PMID 27283531.
- ^ a b c d Benowitz, Neal L.; Burbank, Andrea D. (2016). "Cardiovascular toxicity of nicotine: Implications for electronic cigarette use". Trends in Cardiovascular Medicine. 26: 515–23. doi:10.1016/j.tcm.2016.03.001. ISSN 1050-1738. PMC 4958544 . PMID 27079891.
- ^ 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. doi:10.1164/rccm.201407-1198PP. ISSN 1073-449X. PMID 25006874.
- ^ a b Collaco, Joseph M. (2015). "Electronic Use and Exposure in the Pediatric Population". JAMA Pediatrics. 169 (2): 177–182. doi:10.1001/jamapediatrics.2014.2898. PMID 25546699.
- ^ 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. doi:10.1177/0194599815585752. ISSN 0194-5998. PMID 26002957.
- ^ Detailed reference list is located at a separate image page.
- ^ a b Lachenmeier, Dirk W.; Rehm, Jürgen (2015). "Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach". Scientific Reports. 5: 8126. doi:10.1038/srep08126. ISSN 2045-2322. PMC 4311234 . PMID 25634572.
- ^ Schivo, Michael; Avdalovic, Mark V.; Murin, Susan (February 2014). "Non-Cigarette Tobacco and the Lung". Clinical Reviews in Allergy & Immunology. 46 (1): 34–53. doi:10.1007/s12016-013-8372-0. ISSN 1080-0549. PMID 23673789.
- ^ Callahan-Lyon, P. (2014). "Electronic cigarettes: human health effects". Tobacco Control. 23 (Supplement 2): ii36–ii40. doi:10.1136/tobaccocontrol-2013-051470. ISSN 0964-4563. PMC 3995250 . PMID 24732161.
- ^ Marsot, A.; Simon, N. (March 2016). "Nicotine and Cotinine Levels With Electronic Cigarette: A Review". International Journal of Toxicology. 35 (2): 179–185. doi:10.1177/1091581815618935. ISSN 1091-5818. PMID 26681385.
- ^ a b c d e Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi,