E Cigarettes Uk Where To Buy UK

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.

E Vapor Electronic Cigarette

UK Electronic Cigarettes and E-Liquid

  (Redirected from E-liquid) Aerosol (vapor) exhaled by an e-cigarette user.

The aerosol of electronic cigarettes is generated when the e-liquid reaches a temperature of roughly 100–250 °C within a chamber.[1] The user inhales the aerosol, commonly called vapor, rather than cigarette smoke.[2] The aerosol provides a flavor and feel similar to tobacco smoking.[3] 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.[2] Vapor from an electronic cigarette simulates tobacco smoke, but the process of burning tobacco does not occur.[3] The aerosol is made-up of liquid sub-micron particles of condensed vapor,[4] which mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and other chemicals.[5] The various chemicals in the aerosol give rise to many issues concerning the safety of electronic cigarettes that have been much discussed.[2][5][6] After a puff, inhalation of the aerosol travels from the device into the mouth and lungs.[2] A 2014 review found that the particles emitted by e-cigarettes are comparable in size and number to particles in cigarette smoke, with the majority of them in the ultrafine range. The particles are of the ultrafine size which can go deep in the lungs and then into the systemic circulation. A 2014 review said local pulmonary toxicity may occur because metal nanoparticles can deposit in the lungs.[6] Others show that the quantities of metals emitted are minimal and permissible by medicinal standards.[5][7][8]

Various bottles of e-liquid.

After the aerosol is inhaled, it is exhaled.[2] Emissions from electronic cigarettes are not comparable to environmental pollution or cigarette smoke as their nature and chemical composition are completely different.[5] The particles are larger, with the mean size being 600 nm in inhaled aerosol and 300 nm in exhaled vapor.[9] Bystanders are exposed to these particles from exhaled e-cigarette vapor.[6] 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.[10][11][12] Since e-cigarettes involve an aerosolization process, it is suggested that no meaningful amounts of carbon monoxide are emitted.[13] Thus, cardiocirculatory effects caused by carbon monoxide are not likely.[13] E-cigarette use by an expectant parent might lead to inadvertent health risks to offspring.[14] E-cigarettes pose many safety concerns to children.[14] 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.[14]

E-liquid is the mixture used in vapor products such as electronic cigarettes.[15] The main ingredients in the e-liquid usually are propylene glycol, glycerin, nicotine, and flavorings.[16] However, there are e-liquids sold without propylene glycol, nicotine, or flavors.[15][17][18] The liquid typically contains 95% propylene glycol and glycerin.[19] Propylene glycol and glycerine are used to produce the vapor while the flavoring provides the taste and aroma.[20] The flavorings may be natural or artificial.[9] About 8,000 flavors exist as of 2014.[21] There are many e-liquids manufacturers in the USA and worldwide.[22] While there are currently no US Food and Drug Administration (FDA) manufacturing standards for e-liquid, the FDA has proposed regulations that were expected to be finalized in late 2015.[23] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).[24]

The vapor can contain nicotine and usually contains vegetable glycerin, propylene glycol, flavors and aroma transporters.[8] The nicotine levels in the vapor varies either from puff-to-puff or among products of the same company.[2] A 2015 report commissioned by Public Health England concluded that e-cigarettes "release negligible levels of nicotine into ambient air".[25] E-cigarettes without nicotine are also available.[26] The vapor may also contain tiny amounts of toxicants, carcinogens, and heavy metals.[6][8] Contamination with various chemicals has been identified.[9] E-cigarette makers do not fully disclose information on the chemicals that can be released or synthesized during use.[2] The metals have been found in trace amounts in the vapor, some of them at higher amounts than in cigarette smoke.[5] The peak concentration of nicotine delivered by e-cigarette use is comparable to that produced by conventional cigarette smoking.[27]

An example of a commercial e-liquid and an advanced personal vaporizer.

E-liquid,[28] e-fluid, or e-juice[29] is the mixture used in vapor products including e-cigarettes.[15] E-Liquids come in many variations, including different nicotine strengths and many different flavors.[30] The main ingredients are propylene glycol, glycerine, and flavorings; and most often, nicotine in liquid form.[16] The liquid typically contains 95% propylene glycol and glycerin, and the remaining 5% being flavorings and nicotine.[19] E-liquid can be made with or without nicotine, with >90% of e-liquids containing some level of nicotine.[31] The most regularly used base carrier chemical is propylene glycol with or without glycerin.[6] E-liquid containing glycerin and water made without propylene glycol are also sold.[15] Unless clearly stated, it is uncertain whether the nicotine used in e-liquid is manufactured using a United States Pharmacopeia (USP) grade nicotine, a tobacco plant extract, tobacco dust or a synthetic nicotine.[32] Most e-cigarette liquids contain nicotine, but the level of nicotine varies depending on user-preference and manufacturers.[26] Although some e-juice is nicotine-free, surveys demonstrate that 97% of responders use products that contain nicotine.[17] A 2015 review suggests that 1% of users use liquid without nicotine.[33]

The primary parts that make up an e-cigarette are a mouthpiece, a cartridge (tank), a heating element/atomizer, a microprocessor, a battery, and possibly a LED light on the end.[34] An atomizer comprises a small heating element that vaporizes e-liquid and wicking material that draws liquid onto the coil.[35] When the user pushes a button.[36] or inhales a pressure sensor activates the heating element that atomizes the liquid solution;[37] The e-liquid reaches a temperature of roughly 100–250 °C within a chamber to create an aerosolized vapor.[1] The user inhales the aerosol, commonly called vapor, rather than cigarette smoke.[2] The aerosol provides a flavor and feel similar to tobacco smoking.[3] However, variable voltage devices can raise the temperature where the user adjusts the vapor.[9] The vapor contains similar chemicals to the e-liquid which vary in composition and concentration across and within manufacturers.[2]

E-cigarettes produce particles, in the form of an aerosol.[2][38] 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.[2] The aerosol is made-up of liquid sub-micron particles of condensed vapor,[38] which mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and other chemicals.[5] This aerosol that is produces resembles cigarette smoke.[2] After a puff, inhalation of the aerosol travels from the device into the mouth and lungs.[2]

A 2014 review found that the particles emitted by e-cigarettes are comparable in size and number to particles in cigarette smoke, with the majority of them in the ultrafine range. The ultrafine particles can go deep in the lungs and then into the systemic circulation. Pulmonary toxicity may occur because metal nanoparticles can deposit in the lungs.[6] The review also found that fine particles can be chemically intricate and not uniform, and what a particle is made of, the exact harmful elements, and the importance of the size of the particle is mostly unknown. They found that because these things are uncertain, it is not clear whether the ultrafine particles in e-cigarette vapor have health effects similar to those produced by traditional cigarettes.[6]

A 2014 WHO report found e-cigarettes release a lower level of particles than traditional cigarettes.[39] Comparable to a traditional cigarette, e-cigarette particles are tiny enough to enter the alveoli, enabling nicotine absorption.[29] E-cigarettes companies assert that the particulates produced by an e-cigarette are too tiny to be deposited in the alveoli.[40] Exactly what comprises the vapor varies in composition and concentration across and within manufacturers.[2] Different devices generate different particle sizes and cause different depositions in the respiratory tract, even from the same nicotine liquid.[41] Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern.[42]

After the aerosol is inhaled, it is exhaled.[2] Emissions from electronic cigarettes are not comparable to environmental pollution or cigarette smoke as their nature and chemical composition are completely different.[5] The particles are larger, with the mean size being 600 nm in inhaled aerosol and 300 nm in exhaled vapor.[9] The exhaled aerosol particle concentration is 5 times lower from an e-cigarette than from a combustible tobacco cigarette.[43] The density of particles in the vapor is lower than in cigarette smoke by a factor of between 6 and 880 times lower.[5]

For particulate matter emissions, e-cigarettes slightly exceeded the WHO guidelines, but emissions were 15 times less than traditional cigarette use.[44] In January 2014, the International Union Against Tuberculosis and Lung Disease stated "Adverse health effects for exposed third parties (second-hand exposure) cannot be excluded because the use of electronic cigarettes leads to emission of fine and ultrafine inhalable liquid particles, nicotine and cancer-causing substances into indoor air."[45] The dense vapor consists of liquid sub-micron droplets.[38][dead link]

Since e-cigarettes have not been widely used long enough for evaluation, the long-term health effects from the second-hand vapor are not known.[6] There is insufficient data to determine the impact on public health from e-cigarettes.[46] The potential harm to bystanders from e-cigarettes is unknown.[47] This is because no long-term data is available.[8]

Since e-cigarettes do not burn (or contain) tobacco, no side-stream smoke or any cigarette smoke is produced.[6] Only what is exhaled by e-cigarettes users enters the surrounding air.[8] Exhaled vapor consists of nicotine and some other particles, primarily consisting of flavors, aroma transporters, glycerin and propylene glycol.[8] Bystanders are exposed to these particles from exhaled e-cigarette vapor.[6] A mixture of harmful substances, particularly nicotine, ultrafine particles, and volatile organic compounds can be exhaled into the air.[48] The liquid particles condenses into a viewable fog.[9] The vapor is in the air for a short time, with a half-life of about 10 seconds; traditional cigarette smoke is in the air 100 times longer.[9] This is because of fast revaporization at room temperature.[9]

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.[10][12] Since e-cigarettes involve an aerosolization process, it is suggested that no meaningful amounts of carbon monoxide are emitted.[13] Thus, cardiocirculatory effects caused by carbon monoxide are not likely.[13] However, in an experimental study, e-cigarettes increased levels of carcinogenic polycyclic aromatic hydrocarbons in the surrounding air.[13]

E-cigarettes used in indoor environments can put at risk nonsmokers to elevated levels of nicotine and aerosol emissions.[43] Nonsmokers exposed to e-cigarette aerosol produced by a machine and pumped into a room were found to have detectable levels of the nicotine metabolite cotinine in their blood. The same study stated that 80% of nicotine is normally absorbed by the user, so these results may be higher than in actual second hand exposure.[6] In 2015 a report commissioned by Public Health England concluded that e-cigarettes "release negligible levels of nicotine into ambient air with no identified health risks to bystanders".[25]

A 2014 review of limited data concluded this vapor can cause indoor air pollution and is not just water vapor as is frequently stated in the advertising of e-cigarettes.[6] A 2014 practice guideline by NPS MedicineWise states, "Although data on health effects of passive vapour are currently lacking, the risks are argued to be small, but claims that e-cigarettes emit only water vapour are nevertheless incorrect. Serum cotinine levels (a metabolite of nicotine) have been found to be similar in bystanders exposed to either e-cigarette vapour or cigarette smoke."[49][50] The 2015 California Department of Public Health has reported that "Mainstream and second hand e-cigarette aerosol has been found to contain at least ten chemicals that are on California's Proposition 65 list of chemicals known to cause cancer, birth defects, or other reproductive harm."[51] However, it has been demonstrated that e-cigarettes causes nonusers to be exposed to nicotine but not to tobacco-related combustion toxicants.[10]

A no smoking or vaping sign from the US.

A white paper published in 2014 by the American Industrial Hygiene Association concluded e-cigarettes emit airborne contaminants that may be inhaled by the user and those nearby.[42] They urged indoors restrictions similar to smoking bans, until research has shown the aerosol has no risk of harm.[42] A 2014 review indicated that the levels of inhaled contaminants from the e-cigarette vapor are not of significant health concern for human exposures by the standards used in workplaces to ensure safety.[26] The use of e-cigarettes in a smoke-free area could expose non-users to toxins.[52] The effect on bystanders would likely be much less harmful than traditional cigarettes.[8]

2014 WHO report stated passive exposure was as a concern, indicating that current evidence is insufficient to determine whether the levels of exhaled vapor are safe to involuntarily exposed bystanders.[39] The report stated that "it is unknown if the increased exposure to toxicants and particles in exhaled aerosol will lead to an increased risk of disease and death among bystanders."[39] The British Medical Association (BMA) reported in 2013 that there are "concerns that the use of e-cigarettes could threaten the norm of not smoking in public places and workplaces."[53]

As of 2013[update], the only clinical study currently published evaluating the respiratory effects of passive vaping found no adverse effects were detected.[5] A 2014 review found it is safe to infer that their effects on bystanders are minimal in comparison to traditional cigarettes.[5] A E-cigarette vapor has notably fewer toxicants than cigarette smoke and is likely to pose less harm to users or bystanders.[6]

E-cigarette use by a parent might lead to inadvertent health risks to offspring.[14] E-cigarettes pose many safety concerns to children.[14] 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.[14] A policy statement by the American Association for Cancer Research and the American Society of Clinical Oncology has reported that "Third-hand exposure occurs when nicotine and other chemicals from second-hand aerosol deposit on surfaces, exposing people through touch, ingestion, and inhalation".[17] Public health England, looking at the available research said the amount of nicotine deposited was low and that an infant would have to lick 30 square meters to be exposed to 1 mg of nicotine.[25] The statement noted there are no published studies of third hand exposure from e-cigarettes, however initial data suggests that nicotine from e-cigarettes may stick to surfaces and would be hard to remove.[17]

The e-liquid is sold in bottles or pre-filled disposable cartridges, or as a kit for consumers to make their own e-juices.[54] Some vendors of e-liquids, offer options to change the amounts of flavorings or nicotine strengths, and build each bottle customized for the purchaser.[54] E-liquids are made with various tobacco, fruit, and other flavors,[6] as well as variable nicotine concentrations (including nicotine-free versions).[16] The standard notation "mg/ml" is often used on labels to denote nicotine concentration, and is sometimes shortened to "mg".[55] In surveys of regular e-cigarette users, the most popular e-liquids have a nicotine content of 18 mg/ml, and the preferred flavors were largely tobacco, mint and fruit.[8] A cartridge may contain 0 to 20 mg of nicotine.[48] EU regulations cap the concentration of nicotine in e-liquid at a maximum of 20 mg/mL.[29] A refill bottle can contain up to 1 g of nicotine.[48] Refill liquids are often sold in the size range from 15 to 30 mL.[56] One cartridge may typically last as long as one pack of cigarettes.[57] Some liquids without flavoring is also sold.[18] The flavorings may be natural or artificial.[9] There is even certified organic liquid.[58] About 8,000 flavors exist as of 2014.[21] A user does not normally consume a whole cartridge in a single session.[59] Most e-liquids are produced by a few manufacturers in China, the US and Europe.[8] An e-cigarette user will usually obtain 300 to 500 puffs per mL of liquid.[56]

The two most common e-liquid bases are propylene glycol (PG) and vegetable glycerin (VG).[60] Propylene glycol is tasteless and odorless, and therefore it doesn't affect the flavor of the e-liquid. It is known, however, to cause allergic reactions in some users, and in such case it is advised to stop the use immediately. Vegetable glycerin, on the other hand, is a lot thicker in consistency, and it doesn't cause allergic reactions. It also produces significantly more vapor, which has a slight sweet taste.[61][unreliable source?]

E-liquids are manufactured by many producers, both in the US and across the world.[22] First tier manufacturers use lab suits, gloves, hair covers, inside of certified clean rooms with air filtration similar to pharmaceutical-grade production areas.[22]

Standards for e-liquid manufacturing have been created by American E-liquid Manufacturing Standards Association (AEMSA), which is trade association dedicated to creating responsible and sustainable standards for the safe manufacturing of e-liquids used in vapor products.[62] AEMSA has published a comprehensive list standards and best known methods, which are openly available for use by any manufacturer of e-Liquids. The AEMSA standards cover nicotine, ingredients, sanitary manufacturing rooms, safety packaging, age restrictions, and labeling.[24]

There are no current governmental or US Food and Drug Administration (FDA) manufacturing standards for e-liquid. The FDA has sought to regulate e-liquid through use of the Tobacco Control Act, passed into law in 2009. In April 2014, the FDA issued its "Deeming" proposals for public comment, which would cover e-liquids manufacturing. The Final Rule, (in final form) giving the FDA authority to regulate e-liquids was released on May 5th 2016.[63]

Fifty One Electronic Cigarette

Electronic cigarette

 UK

The entering into force of the requirements of the European tobacco products directive in Estonia made e-cigarette seller Nicorex Baltic destroy 19,000 bottles of e-cigarette liquid worth €135 000, as the packaging size did not meet the new requirements.

The liquids were actually in order, had undergone laboratory testing and met the new requirements, but their packaging did not have the necessary warnings on them and the boxes did not contain instructions.

Nicorex said that the transition period allowed by the government was too short, as the shelf life of the liquids was two years, but the length of the transition period only one year.

At the same time, Nicorex welcomed the requirement that the liquids have to undergo laboratory testing and that both the equipment and liquids must be registered in a single European database.

Nicorex described the restrictions concerning the size of packaging as unreasonable, as they increased the ecological footprint.

The transition period under the new tobacco law arising from the European tobacco products directive will end on May 20, after which the stricter requirements will apply to e-cigarettes in full.

Liquids can't be sold in containers bigger than 10 ml, they can't contain more nicotine than 20 milligrams per milliliter, and the vaporizer can't be bigger than 2 ml.

The packaging needs to include a leaflet, instructions, a batch number, a date, and a warning that nicotine is an addictive substance.


 

Uk E Liquid Free Delivery UK

Uk Vape Online UK

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.

Electronic Cigarette Buy

UK Electronic Cigarettes and E-Liquid

  (Redirected from Health effects of electronic cigarettes)

The safety of electronic cigarettes is uncertain.[1][2][3] There is little data about their safety, and considerable variability among e-cigarettes and in their liquid ingredients[4] and thus the contents of the aerosol delivered to the user.[5] Reviews on the safety of e-cigarettes have reached significantly different conclusions.[6] A 2014 World Health Organization (WHO) report cautioned about potential risks of using e-cigarettes.[7] Regulated US Food and Drug Administration (FDA) products such as nicotine inhalers are likely safer than e-cigarettes,.[8] 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.[9][10][11] However, e-cigarettes cannot be considered harmless.[12]

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.[3][13] The long-term effects of e-cigarette use are unknown.[13][14][15] 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.[16] Less serious adverse effects may include abdominal pain, headache, blurry vision,[16] throat and mouth irritation, vomiting, nausea, and coughing.[5] A 2014 WHO report said, "ENDS [electronic nicotine delivery system] use poses serious threats to adolescents and fetuses."[7] Aside from toxicity exposure in normal use, there are also risks from misuse or accidents[9] such as nicotine poisoning (especially among infants and children),[17] contact with liquid nicotine,[18] fires caused by vaporizer malfunction,[5] and explosions resulting from extended charging, unsuitable chargers, or design flaws.[9] Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns.[1] There is a small risk of battery explosion in devices modified to increase battery power.[19]

The cytotoxicity of e-liquids varies,[20] and contamination with various chemicals have been detected in the liquid.[21] Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals.[9] 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.[22] Normal usage of e-cigarettes,[23] and reduced voltage (3.0 V[24]) devices generate very low levels of formaldehyde.[22] Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[14][Notes 1] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[25] A 2015 Public Health England (PHE) report found that high levels of formaldehyde only occurred in overheated "dry-puffing".[26] 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."[27] However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.[19] E-cigarette users who use devices that contain nicotine are exposed to its potentially harmful effects.[24] Nicotine is associated with cardiovascular disease, potential birth defects, and poisoning.[28]In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo.[28] There is inadequate research to demonstrate that nicotine is associated with cancer in humans.[29] The risk is probably low from the inhalation of propylene glycol and glycerin.[13] No information is available on the long-term effects of the inhalation of flavors.[21]

E-cigarettes create an aerosol that consists of fine and ultrafine particles of particulate matter, with the majority of particles in the ultrafine range.[5][30] 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.[5][13] Exactly what the vapor comprises varies in composition and concentration across and within manufacturers.[24] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.[31] The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor.[9] E-cigarette vapor contains lower concentrations of potentially toxic chemicals than with cigarette smoke.[32] Those which are present, are mostly below 1% the corresponding levels permissible by workplace safety standards.[33] 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.[5] Concern exists that some of the mainstream vapor exhaled by e-cigarette users may be inhaled by bystanders, particularly indoors.[34] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[35] A 2014 review recommended that e-cigarettes should be regulated for consumer safety.[36] There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges.[37]

Reviews on the safety of e-cigarettes, evaluating roughly the same studies, have reached significantly different conclusions.[6] Due to various methodological issues, severe conflicts of interest, and inconsistent research, no definite conclusions can be determined regarding the safety of e-cigarettes.[12] However, e-cigarettes cannot be regarded as harmless.[12] There is little data about their safety, and considerable variability among vaporizers and in their liquid ingredients[4] and thus the contents of the aerosol delivered to the user.[5] 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.[36] 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.[38] 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."[17] 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.[7]

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.[39] A 2014 review recommended that e-cigarettes could be adequately regulated for consumer safety with existing regulations on the design of electronic products.[36] Regulation of the production and promotion of e-cigarettes may help lower some adverse effects associated with tobacco use.[34] 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.[40] 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.[40] The industry could also lead vapers to tobacco products, which would increase instead of decrease overall addiction.[40]

The health effects related to e-cigarette use is mostly unknown.[41] The health effects on intensive e-cigarette users are unknown.[14] The effect on population health from e-cigarettes is unknown.[8] 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."[42] 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."[43] The American Diabetes Association states "There is no evidence that e-cigarettes are a healthier alternative to smoking."[44] In August 2014, the Forum of International Respiratory Societies stated that e-cigarettes have not been demonstrated to be safe.[45]Health Canada has stated that, "their safety, quality, and efficacy remain unknown."[46] 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."[47]

Effects of vaping, compared to tobacco smoking.[48]

A 2015 Public Health England (PHE) report stated that e-cigarettes are estimated to be 95% less harmful than smoking,[49] although this estimate has been disputed.[50] 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."[51] 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.[9] 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.[52] Scientific studies advocate caution before designating e-cigarettes as beneficial but vapers continue to believe they are beneficial.[53]

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."[54] 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."[55] 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.[56] 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."[57] No long-term studies have evaluated future tobacco use as a result of e-cigarette use.[58] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.[31]

Possible adverse effects of vaping.[59]

As of 2015, the short-term and long-term effects from using e-cigarettes remain unclear.[14]Adverse effects are mostly associated with short-term use and the reported adverse effects decreased over time.[60] Long-term studies regarding the effects of constant use of e-cigarettes are unavailable.[60] The adverse effects of e-cigarettes on people with cancer is unknown.[17] A 2014 Cochrane review found no serious adverse effects reported in trials,[61] but serious events have been reported in case studies.[13]

The evidence suggests they produce less harmful effects than combusted tobacco.[11] 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.[53] Many health benefits are associated with switching from tobacco to e-cigarettes including decreased weight gain after smoking cessation and improved exercise tolerance.[62] 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.[63] Many people use e-cigarettes to quit smoking, but few succeed.[64] They frequently use both, which increases their health risks by using both products.[64] Quitting smoking entirely would probably have much greater beneficial effects to overall health than vaping to decrease the number of cigarettes smoked.[5]

More serious adverse effects frequently related with smoking cessation including depression, insomnia, and anxiety are uncommon with e-cigarette use.[16] 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.[16] Less serious adverse effects include abdominal pain, headache, blurry vision,[16] throat and mouth irritation, vomiting, nausea, and coughing.[5] Short-term adverse effects reported most often were mouth and throat irritation, dry cough, and nausea.[60] The majority of adverse effects reported were nausea, vomiting, dizziness and oral irritation.[9] 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.[22] 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.[17]

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.[13] 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.[41] The man from the UK reportedly died from severe lipoid pneumonia in 2011.[41] Reports to the Food and Drug Administration (FDA) for minor adverse effects identified with using e-cigarettes include headache, chest pain, nausea, and cough.[1] Major adverse effects reported to the FDA included hospitalizations for pneumonia, congestive heart failure, seizure, rapid heart rate, and burns.[1] 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.[1] 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.[65] 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.[66] E-cigarettes were associated with fewer adverse effects than nicotine patches.[67]

Symptoms of nicotine poisoning related to e-cigarette calls to US poison control centers.[68]

Nicotine poisoning related to e-cigarettes include ingestion, inhalation, or absorption via the skin or eyes.[17] Accidental poisoning can result from using undiluted concentrated nicotine when mistakenly used as prepared e-liquids.[69] E-cigarettes involve accidental nicotine exposure in children.[18] Accidental exposures in pediatric patients include ingesting of e-liquids and inhaling of e-cigarette vapors.[18] Choking on e-cigarette components is a potential risk.[18] It is recommended that youth access to e-cigarettes be prohibited.[70]

Four adults died in the US and Europe, after intentionally ingesting liquid.[41] Two children, one in the US in 2014 and another in Israel in 2013, died after ingesting liquid nicotine.[71] Death from accidental nicotine poisoning is very uncommon.[72]

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.[73] Minor, moderate, and serious adverse effects involved adults and young children.[74] Minor effects correlated with e-cigarette liquid poisoning were tachycardia, tremor, chest pain and hypertension.[75] More serious effects were bradycardia, hypotension, nausea, respiratory paralysis, atrial fibrillation and dyspnea.[75] The exact correlation is not fully known between these effects and e-cigarettes.[75] 58% of e-cigarette calls to US poison control centers were related to children 5 years old or less.[74] 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.[74] Most of the e-cigarette and traditional cigarette calls were a minor effect.[74] Severe outcomes were more than 2.5 times more frequent in children exposed to e-cigarettes and nicotine e-liquid than with traditional cigarettes.[76] 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%.[74]

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.[77]

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;[74] inhalation/nasal exposure resulted in nausea, vomiting, dizziness, agitated, or headache;[74] ocular exposure resulted in eye irritation or pain, red eye or conjunctivitis, blurred vision, headache, or corneal abrasion;[74] multiple routes of exposure resulted in eye irritation or pain, vomiting, red eye or conjunctivitis, nausea, or cough;[74] and dermal exposure that resulted in nausea, dizziness, vomiting, headache, or tachycardia.[74] 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%).[74] In nine reported calls, exposed individuals stated the device leaked.[74] In five reported calls, individuals used e-liquid for their eyes rather than use eye drops.[74] In one reported call, an infant was given the e-liquid by an adult who thought it was the infant's medication.[74] There were also reports of choking on e-cigarette components.[18]

From January 1, 2016 and April 30, 2016, the American Association of Poison Control Centers (AAPCC) reported 623 exposures related to e-cigarettes.[64] The AAPCC reported 3,067 exposures relating to e-cigarettes and liquid nicotine in 2015, and 3,783 in 2014.[78] From September 1, 2010 to December 31, 2014, there were at least 5,970 e-cigarette calls to US poison control centers.[74] 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%.[67] 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.[75] E-cigarette calls was 401 for the month of April 2014.[74] 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.[9]

Fruit flavored e-liquids.

There is a possibility that inhalation, ingestion, or skin contact can expose people to high levels of nicotine.[34] Concerns with exposure to the e-liquids include leaks or spills and contact with contaminants in the e-liquid.[79] This may be especially risky to children, pregnant women, and nursing mothers.[34] The liquid quickly absorbs into the skin.[80] The nicotine in e-liquid can be hazardous to infants.[81] Even a portion of e-liquid may be lethal to a little child.[82] An excessive amount of nicotine for a child that is capable of being fatal is 0.1–0.2 mg/kg of body weight.[34] Less than a 1 tablespoon of contact or ingestion of e-liquid can cause nausea, vomiting, cardiac arrest, seizures, or coma.[83] An accidental ingestion of only 6 mg may be lethal to children.[38][84]

Children are susceptible to ingestion due to their curiosity and desire for oral exploration.[76] E-cigarettes are packed in colorful containers[74] and children may be attracted to the flavored liquids.[58] More youth-oriented flavors include "My Birthday Cake" or "Tutti Frutti Gumballs".[71] Many nicotine cartridges and bottles of liquid are not child-resistant to stop contact or accidental ingestion of nicotine by children.[11] "Open" e-cigarette devices, with a refillable tank for e-liquids, are believed to be the biggest risk to young children.[83] It is recommended that e-cigarettes be kept in a safe place, where children and pets do not have access to them.[85]

Nicotine toxicity is of concern when e-cigarette solutions are swallowed intentionally by adults as a suicidal overdose.[40] Six people attempted suicide by injecting e-liquid.[41] One adolescent attempted suicide by swallowing the e-liquid.[18] Three deaths were reported to have resulted from swallowing or injecting e-liquid containing nicotine.[41] An excessive amount of nicotine for an adult that is capable of being fatal is 0.5–1 mg/kg of body weight.[34] An oral lethal dose for adults is about 30–60 mg.[53] 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.[86] Reports of serious adverse effects associated with acute nicotine toxicity that resulting in hospitalization were very uncommon.[87] Death from intentional nicotine poisoning is very uncommon.[72] Clear labeling of devices and e-liquid could reduce unintentional exposures.[74] Child-proof packaging and directions for safe handling of e-liquids could minimize some of the risks.[81] In January 2016, the Child Nicotine Poisoning Prevention Act of 2015 was passed into law in the US,[88] which requires child-proof packaging.[89]

There was inconsistent labeling of the actual nicotine content on e-liquid cartridges from some brands,[5] and some nicotine has been found in ‘no nicotine' liquids.[21] A 2015 PHE report noted overall the labelling accuracy has improved.[90] Most inaccurately-labelled examples contained less nicotine than stated.[90] Due to nicotine content inconstancy, it is recommended that e-cigarette companies develop quality standards with respect to nicotine content.[24]

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.[81] 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.[38] This includes leaking cartridges, accidental contact with nicotine when changing cartridges, and potential of unintended overdose.[38] 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."[91]

Cannabinoid-containing e-liquids need lengthy, complex processing, some being available online without any toxicological and clinical evaluation.[92] 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.[92] The health effects of vaping cannabis formulations is mostly unknown.[92]

Most e-cigarettes use lithium batteries, the improper use of which may result in accidents.[9] It has been recommended that manufacturing quality standards be imposed in order to prevent such accidents.[9] Better product design and standards could probably reduce some of the risks.[79] Concern exists from risks associated with e-cigarette explosions for children and adults.[18]

Some batteries are not well designed, are made with poor quality components, or have defects.[1] Major injuries have occurred from battery explosions and fires.[5] 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.[93] A young man endured bilateral corneal burns to the eye area when an e-cigarette exploded near his chest.[93] E-cigarette explosions have resulted in burns, lost teeth, neck fractures, and battery acid contact to the face, mouth, and eyes.[93] A man died when charging an e-cigarette blown up and caught on fire next to oxygen equipment.[93] House and car fires and skin burns have resulted from some of the explosions.[1] The explosions were the result of extended charging, use of unsuitable chargers, or design flaws.[9] There is a possible risk to bystanders from e-cigarette explosions.[93] There is also a risk of property damage as a result of flammable materials catching on fire from an e-cigarette explosion.[93] The United States Fire Administration said that 25 fires and explosions were caused by e-cigarettes between 2009 and August 2014.[94] In the UK fire service call-outs had risen, from 43 in 2013 to 62 in 2014.[95] A 2015 PHE report concluded that the risks of fire from e-cigarettes "appear to be comparable to similar electrical goods".[96] 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.[93] There is inadequate product labeling to inform users of the possible serious harms.[93] The risk from serious adverse effects is low, but the aftermath may be disastrous in respect to an e-cigarette blast.[93] Victims have filed lawsuits to make restitution from the e-cigarette blasts.[41] Adverse effects may be under-reported because reports to the FDA is voluntary.[93]

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.[94][97] The International Civil Aviation Organization, a United Nations agency, also recommends prohibiting e-cigarettes in checked luggage.[94] 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.[94] In-flight use of e-cigarettes is prohibited in the US.[97]

Users may alter many of the devices, such as using them to administer other drugs like cannabis.[5] E-liquid mixing is another way users tamper with e-cigarettes.[98] Mixing liquid in an unclean area runs the risk of contamination.[16] Users may add various flavorings and diluents.[98] Vodka or other forms of alcohol may also be added.[98] The addition of alcohol or nicotine could expose the user to more toxicants, especially when added in combinations.[98] 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.[98] Users can adjust the voltage of some e-cigarettes.[98] 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.[19] Some users add more or larger batteries to nonadjustable e-cigarettes, which may lead to battery leakage or explosion.[98] 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.[18]

The long-term health impacts of e-cigarette use are unknown.[13] The long-term health impacts of the main chemicals nicotine and propylene glycol in the aerosol are not fully understood.[99] There is limited peer-reviewed data about the toxicity of e-cigarettes for a complete toxicological evaluation,[100] and their cytotoxicity is unknown.[15] The chemicals and toxicants included in e-cigarettes have not been completely disclosed and their safety is not guaranteed.[34] They are similar in toxicity to other nicotine replacement products,[101] but e-cigarettes manufacturing standards are variable standards, and many as a result are probably more toxic than nicotine replacement products.[102] 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.[103] 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.[36]

Concerns about the carcinogenicity of e-cigarettes arise from both nicotine[28] and from other chemicals that may be in the vapor.[24] 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.[28] 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".[29] 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".[29] Nicotine in the form of nicotine replacement products is less of a risk than compared to smoking,[29] and they have not been shown to be associated with cancer in the real world.[28]

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.[8] 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."[99] The e-cigarette vapors triggered DNA strand breaks and lowered cell survival in vitro.[41] 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.[10] 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."[104]

Chart showing various toxicants as measured in cigarette smoke and e-cigarette aerosol.[105]

Since nicotine-containing e-liquids are made from tobacco they may contain impurities like cotinine, anabasine, anatabine, myosmine and beta-nicotyrine.[13] The majority of e-cigarettes evaluated included carcinogenic tobacco-specific nitrosamines (TSNAs); heavy metals such as cadmium, nickel, and lead; and the carcinogen toluene.[34] However, in comparison to traditional cigarette smoke, the toxic substance levels identified in e-cigarette vapor were 9- to 450-fold less.[34] E-liquid with tin was cytotoxic.[12] E-cigarettes cannot be considered absolutely safe because there is no safe level for carcinogens.[106]

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.[8] 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."[107]

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."[24] Few of the methods used to analyze the chemistry of e-cigarettes in the studies the review evaluated were validated.[24]

The propylene glycol molecule.

The primary base ingredients of the liquid solution is propylene glycol and glycerin.[5] About 20% to 27% of propylene glycol and glycerin-based liquid particles are inhaled.[108] The long-term effects of inhaled propylene glycol has not been studied,[58] and is unknown.[109] The effects of inhaled glycerin are unknown.[84] Being exposed to propylene glycol may cause irritation to the eyes and respiratory tract.[5] The risk from the inhalation of propylene glycol and glycerin is probably low.[13] Propylene glycol and glycerin have not been shown to be safe.[84] Some research states that propylene glycol emissions may cause respiratory irritation and raise the likelihood to develop asthma.[52] Long-term inhalation of propylene glycol indoors could increase risk to children to develop asthma.[38] To lessen the risks, most e-cigarettes companies began to use water and glycerin as replacement for propylene glycol.[52] The inhaled glycerin could cause lipoid pneumonia.[16]

Some e-cigarette products had acrolein identified in the aerosol.[13] It may be generated when glycerin is heated to higher temperatures.[13] Acrolein may induce irritation to the upper respiratory tract.[5] Acrolein levels were reduced by 60% in dual users and 80% for those that completely switched to e-cigarettes when compared to traditional cigarettes.[13] E-cigarettes vapor have been found to create oxidants and reactive oxygen species (OX/ROS).[19] OX/ROS could react with other substances in the vapor because they are highly reactive.[19] 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.[19]

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.[100] 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.[33] The short-term toxicity of e-cigarette use appears to be low, with the exception for some people with reactive airways.[21]

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.[21] The cytotoxicity of e-liquids varies,[20] and contamination with various chemicals have been detected in the liquid.[21] Some liquids were very toxic and others had little or no cytotoxicity.[20] The cytotoxicity is mostly due to the amount and number of flavors added.[20] Since nicotine has a bitter taste, nicotine e-liquids contain chemicals to cover up the nicotine taste.[19] The liquids contain aromatic substances like tobacco, fruit, vanilla, caramel and coffee.[21] Generally, these additives are imprecisely described, using terms such as "vegetable flavoring".[21] Although they are approved for human consumption there are no studies on the short-term or long-term effects of inhaling them.[21] The safety of inhaling flavors is mostly unknown,[110] and their safety has not been determined by the Flavor and Extract Manufacturers Association.[41] In some cases e-liquids contain very large amounts of flavorings, which may cause irritation and inflammation on respiratory and cardiovascular systems.[69] Some flavors are regarded as toxic and a number of them resemble known carcinogens.[21] Some artificial flavors are known to be cytotoxic.[21] Unflavored vapor is less cytotoxic than flavored vapor.[23] 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.[111]

Cinnamaldehyde has been described as a highly cytotoxic material in vitro in cinnamon-flavored refill liquids.[1] 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.[9] Some e-liquids containing cinnamaldehyde stimulate TRPA1, which might induce effects on the lung.[19] E-liquids contain possibly toxic aldehydes and reactive oxygen species (ROS).[19] Many flavors are known aldehydes, such as anisaldehyde, cinnamaldehyde, and isovaleraldehyde.[19] The effects of aldehyde-containing flavors on pulmonary surfaces are unknown.[19] A 2012 study found butterscotch flavor was highly toxic with one liquid and two others had a low toxicity.[40] 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.[34] Some additives may be added to reduce the irritation on the pharynx.[84] The long-term toxicity is subject to the additives and contaminants in the e-liquid.[21]

Certain flavorings contain diacetyl and acetyl propionyl which give a buttery taste.[31] Diacetyl and acetyl propionyl are associated with bronchiolitis obliterans.[31] 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.[6] Both diacetyl and acetyl-propionyl have been found in concentrations above those recommended by the US National Institute for Occupational Safety and Health.[31] Diacetyl is normally found at lower levels in e-cigarettes than in traditional cigarettes.[31] Concerns exist that the flavors and additives in e-cigarettes might lead to diseases, including the popcorn lung.[112] The cardiovascular effects, including a vast range of flavorings and fragrances, is unknown.[113] 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.[62] The precise ingredients of e-cigarettes are not known.[114]

The IARC has categorized formaldehyde as a human carcinogen, and acetaldehyde is categorized as a potential carcinogenic to humans.[22] Aldehydes may cause harmful health effects; though, in the majority of cases, the amounts inhaled are less than with traditional cigarettes.[22] 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,[22] to high temperatures.[34] These compounds are frequently identified in e-cigarette aerosols.[22] The propylene glycol-containing liquids produced the most amounts of carbonyls in e-cigarette aerosols.[22] 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.[5] Nearly all e-cigarettes evaluated, toxic and irritation-causing carbonyls were identified.[34] Reports regarding the levels of toxic chemicals were inconsistent.[34] This includes a study showing that the levels of toxicants in e-cigarettes may be higher than with cigarette smoke.[34]

Battery output voltage influences the level of the carbonyl substances in the vapor.[22] A few new e-cigarettes let users boost the amount of vapor and nicotine provided by modifying the battery output voltage.[22] E-cigarettes with higher voltages (5.0 V[20]) can emit carcinogens including formaldehyde at levels comparable to cigarette smoke,[115] while reduced voltages (3.0 V[24]) generate aerosol with levels of formaldehyde and acetaldehyde roughly 13 and 807-fold less than in cigarette smoke.[22] "Dripping", where the liquid is dripped directly onto the atomizer, can create carbonyls including formaldehyde.[116]

A 2015 PHE report found that normal e-cigarette use generates very low levels of aldehydes.[26] Normal usage of e-cigarettes generates very low levels of formaldehyde,[23] and at normal settings they generate very low levels of formaldehyde.[26] Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[14][Notes 2] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[25] 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.[26] 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."[27] However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.[19]

Possible side effects of nicotine.[117] 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.[118] Shown above is the MOE for daily drug use from the analysis.[118]

Pregnant women, breastfeeding mothers, and the elderly are more sensitive to nicotine than other individuals.[110] There are safety issues with the nicotine exposure from e-cigarettes, which may cause addiction and other adverse effects.[24] Nicotine is regarded as a potentially lethal poison.[17] Concerns exist that vaping can be harmful by exposing users to toxic levels of nicotine.[17] At low amounts, it has a mild analgesic effect.[110] At high enough doses, nicotine may result in nausea, vomiting, diarrhea, salivation, bradyarrhythmia, and possibly seizures and hypoventilation.[35] 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.[17] The health effects of nicotine in infants and children are unclear.[35]

E-cigarettes provide nicotine to the blood quicker than nicotine inhalers.[53] The levels were above that of nicotine replacement product users.[17] E-cigarettes seem to have a pharmacokinetic nicotine profile closer to nicotine replacement products than with traditional cigarettes.[119] How efficiently different e-cigarettes give nicotine is unclear.[17]Serum cotinine levels are comparable to that of traditional cigarettes,[120] but are inharmonious and rely upon the user and the device.[8] Blood nicotine levels raised more gradually and took more time to get to peak concentration with e-cigarettes than with traditional cigarettes.[121]

When compared to traditional cigarettes older devices usually delivered low amounts of nicotine.[17] 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.[122] This is due to the minute nicotine particles in the vapor, which permit quick delivery into the bloodstream.[122] The nicotine delivered from e-cigarettes enters the body slower than traditional cigarettes.[123] Studies suggest that inexperienced users obtain moderate amounts of nicotine from e-cigarettes.[124] Concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device.[125]

Later-generation e-cigarettes gives nicotine more effectively than first-generation e-cigarettes.[1] Later-generation models with concentrated nicotine liquids may deliver nicotine at levels similar to traditional cigarettes.[17] E-cigarettes with stronger batteries heat solutions to higher temperatures, which may raise blood nicotine levels to those of traditional cigarettes.[40] Research suggests that experienced e-cigarettes users are able to get as much nicotine from e-cigarettes as traditional cigarettes.[17] Later-generation e-cigarettes containing sufficient nicotine elevates heart rate comparable to traditional cigarettes.[113]

The health effects of long-term nicotine use is unknown.[109] It may be decades before the long-term health effects of nicotine vapor inhalation is known.[126] It is not recommended for non-smokers.[9] Nicotine affects practically every cell in the body.[110] Nicotine can cause high blood pressure and abnormal heart rhythms.[107] Vapers that get a higher amount of blood nicotine are probably correlated with increased heart rates.[87] Nicotine may have adverse effects on lipids,[127] cause insulin resistance.[40] and can lower coronary blood flow.[113] Nicotine lowers estrogen levels and has been associated with early menopause in women.[107] Nicotine could have cancer-promoting properties, therefore long-term use may not be harmless.[98] Nicotine may result in neuroplasticity variations in the brain.[80] Nicotine could make cancer therapies less effective.[16]

Children are more sensitive to nicotine than adults.[110] In youth, nicotine may affect capabilities connected with higher cognitive function processes,[35] later achievement, as well as the chance of nicotine addiction for life.[107] The adolescents developing brain is especially sensitive to the harmful effects of nicotine.[82] A short period of regular or occasional nicotine exposure in adolescence exerts long-term neurobehavioral damage.[82] In August 2014, the American Heart Association noted that "e-cigarettes could fuel and promote nicotine addiction, especially in children."[40] 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."[128]

There is limited evidence on the long-term exposure of metals.[9] Exposure to the levels and kinds of metals found in the aerosol relies upon the material and other manufacturing designs of the heating element.[40] 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.[9] The device itself could contribute to the toxicity from the tiny amounts of silicate and heavy metals found in the liquid and vapor,[116] because they have metal parts that come in contact with the e-liquid.[9] Low levels of possibly harmful chromium, lead, and nickel metals have been found in the emissions.[40] Chromium and nickel nanoparticles have also been found.[5]

Metals may adversely affect the nervous system.[70] A 2013 review found metallic and nanoparticles are associated with respiratory distress and disease.[129] 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.[34] A 2013 study found metal particles in the aerosol were at levels 10-50 times less than permitted in inhalation medicines.[13] A 2014 review suggested that there is no evidence of contamination of the aerosol with metals that justifies a health concern.[33]

Abbreviations: μg, microgram; ng, nanogram; ND, not detected.[20]
∗Fifteen puffs were chosen to estimate the nicotine delivery of one traditional cigarette.[20]

The risks to the lungs are not fully understood,[19] and concern exists regarding the negative effects on lung function.[130] There is limited evidence on the long-term health effects to the lungs.[14] Many ingredients used in e-liquids have not been examined in the lung.[19] The effects of e-cigarette use in respect to asthma and other respiratory diseases are unknown.[13] A 2015 review found e-cigarettes may induce acute lung disease.[14] A 2015 study found that e-cigarette vapors can induce oxidative stress in lung endothelial cells.[69] 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.[41] The limited evidence suggests that e-cigarettes produce less short-term effects on lung function than traditional cigarettes.[8] A 2014 case report observed the correlation between sub-acute bronchiolitis and vaping.[14] After quitting vaping the symptoms improved.[14]

The long-term effects regarding respiratory flow resistance are unknown.[60] E-cigarettes could harm the respiratory system.[21] The immediate effects of e-cigarettes after 5 minutes of use on pulmonary function resulted in considerable increases in resistance to lung airflow.[1] A 2013 review found an instant increase in airway resistance after using a single e-cigarette.[21] Any reported harmful effects to cardiovascular and respiratory functions after short-term use of e-cigarettes were appreciably milder in comparison to cigarette smoke.[9] When used in the short-term, an e-cigarette resulted in a rise of respiratory resistance comparatively to traditional cigarettes.[60] E-cigarette use could result in respiratory diseases among youth.[131]

There is no data available on the long-term cardiovascular effects.[8] There is no published research available on vaping and thrombosis, platelet reactivity, atherosclerosis, or blood vessel function.[14] 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.[122] Some case reports documented the possible cardiovascular adverse effects from using e-cigarettes, the majority associated was with improper use.[122] 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.[122] E-cigarette use leads to sympathomimetic effects because of nicotine intake.[132] It is argued that there could be a risk for harmful effects, including tachycardia-induced cardiomyopathy.[132] E-cigarettes containing nicotine may have a lower cardiovascular effect than traditional cigarettes containing nicotine.[113] Short-term physiological effects include increases in blood pressure and heart rate.[14] A 2012 case report found a correlation between paroxysmal atrial fibrillation and vaping.[14]

Comparable to a traditional cigarette, e-cigarette particles are tiny enough to enter the alveoli, enabling nicotine absorption.[1] These particles are also tiny enough to go deep in the lungs and enter into the systemic circulation.[5] Local pulmonary toxicity may occur because metal nanoparticles can deposit in the lung's alveolar sacs.[5] E-cigarettes companies assert that the particulates produced by an e-cigarette are too tiny to be deposited in the alveoli.[53] Different devices generate different particle sizes and cause different depositions in the respiratory tract, even from the same nicotine liquid.[115] The aerosol production of e-cigarettes during vaping decreases, which requires a more forceful suction to create a similar volume of aerosol.[66] A more forceful suction could affect the deposition of substances into the lungs.[66] Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern.[133]

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.[87] There were reports of e-cigarettes causing an immune system reaction involving inflammation of the gastrointestinal system.[41] Long-term use could increase the risk of tuberculosis.[12] It is possible that e-cigarettes could harm the periodontium because of the effects of nicotine on gum tissues and the immune system.[134] 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.[87]

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.[19] The user inhales the aerosol, commonly called vapor, rather than cigarette smoke.[24] 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.[24] The aerosol is made-up of liquid sub-micron particles of condensed vapor,[135] which mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and other chemicals.[9] After a puff, inhalation of the aerosol travels from the device into the mouth and lungs.[24] 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.[5]

Various bottles of e-liquid.

After the aerosol is inhaled, it is exhaled.[24] Emissions from electronic cigarettes are not comparable to environmental pollution or cigarette smoke as their nature and chemical composition are completely different[9] The particles are larger, with the mean size being 600 nm in inhaled aerosol and 300 nm in exhaled vapor.[21] Bystanders are exposed to these particles from exhaled e-cigarette vapor.[5] 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.[34][129] Since e-cigarettes involve an aerosolization process, it is suggested that no meaningful amounts of carbon monoxide are emitted.[123] Thus, cardiocirculatory effects caused by carbon monoxide are not likely.[123] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[35] E-cigarettes pose many safety concerns to children.[35] 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.[35]

E-liquid is the mixture used in vapor products such as electronic cigarettes.[52] The main ingredients in the e-liquid usually are propylene glycol, glycerin, nicotine, and flavorings.[101] However, there are e-liquids sold without propylene glycol, nicotine, or flavors.[17][52][61] The liquid typically contains 95% propylene glycol and glycerin.[84] The flavorings may be natural or artificial.[21] About 8,000 flavors exist as of 2014.[136] There are many e-liquids manufacturers in the USA and worldwide.[137] 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.[138] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).[139]

Concerns exists regarding pregnant women exposure to e-cigarette vapor through direct use or via exhaled vapor.[5] No evidence have shown that e-cigarettes are safe to use for pregnant women.[140] No amount of nicotine is safe for pregnant women.[140] 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.[8] E-cigarette are assumed to be dangerous to the fetus during pregnancy if e-cigarettes are used by the mother.[141] Nicotine is harmful to the growing fetus.[142] Nicotine accumulates in the fetus because it goes through the placenta.[38]

As of 2015[update], the long-term issues of e-cigarettes on both mother and unborn baby are unknown.[143] 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.[140] Prenatal nicotine exposure is associated with lower birth weights than other babies,[140]stillbirth,[82]sudden infant death syndrome, and alterations to normal brain development.[140] Prenatal nicotine exposure is associated with asthma and wheezing which may continue into adulthood.[140]Gestational age nicotine exposure is associated with many neurological deficits.[140] Prenatal exposure has been associated with obesity, diabetes, high cholesterol and high blood pressure in minors.[107] Prenatal nicotine exposure in females may lead toward early menarche.[140] An infant was born with necrotizing enterocolitis due to e-cigarette use during pregnancy.[41]

In what way the e-liquid ingredients could affect a fetus is unknown.[2] 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.[109] There are concerns about the health impacts of pediatric exposure to second-hand and third-hand e-cigarette vapor.[18] 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."[17] The belief that e-cigarettes are safer than traditional cigarettes could increase their use in pregnant women.[1] The toxic effects identified with e-cigarette refill liquids on stem cells may be interpreted as embryonic death or birth defects.[1] 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.[35] There is concern for breastfeeding women using e-cigarettes, due to the lack of data on propylene glycol transferring to breastmilk.[21]

There is limited information available on any environmental issues connected to the production, usage, and disposal of e-cigarette models that use cartridges.[37] 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.[37] 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.[37] It is not clear which manufacturing methods are used to make the nicotine used in e-cigarettes.[37] The emissions from making nicotine could be considerable from manufacturing if not appropriately controlled.[37] Some e-cigarette brands that use cartridges state their products are ‘eco-friendly’ or ‘green’, despite the absence of any supporting studies.[37] Some writers contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors.[37]

It is unclear how many traditional cigarettes are comparable to using one e-cigarette that uses a cartridge for the average user.[37] Information is limited on energy and materials used for production of e-cigarettes versus traditional cigarettes, for comparable use.[37] E-cigarettes can be made manually put together in small factories, or they can be made in automated lines on a much bigger scale.[37] Larger plants will produce greater emissions to the surrounding environment, and thus will have a greater environmental impact.[37] 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.[37] A 2014 review found "disposable e-cigarettes might cause an electrical waste problem."[123] Since the majority of e-cigarettes are reusable they are possibly more environmentally friendly than using single-use devices.[144] Compared to traditional cigarettes, e-cigarettes do not create litter in the form of discarded cigarette butts.[144] Traditional cigarette tend to end up in the ocean where they cause pollution.[144]

Marketing and advertisement affects the public’s perception of e-cigarettes.[109] Some tobacco users think vaping is safer than tobacco or other smoking cessation aids.[145] It is generally considered by users that e-cigarettes are safer than tobacco.[114] Many users think that e-cigarettes are healthier than traditional cigarettes for personal use or for other people.[58] Usually, only a small proportion of users are concerned about the possible adverse health effects or toxicity of e-cigarettes.[58] 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.[146] A 2013 four-country survey found higher than 75% of current and former smokers think e-cigarettes are safer than traditional cigarettes.[1] 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".[147] 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."[147] 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."[147]

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.[148] 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?][149]

  1. ^ 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. 
  2. ^ 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. 
  3. ^ 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. 
  4. ^ 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. 
  5. ^ 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. 
  6. ^ 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. 
  7. ^ a b c "Electronic nicotine delivery systems" (PDF). WHO. pp. 1–13. Retrieved 28 August 2014. 
  8. ^ 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. 
  9. ^ 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. 
  10. ^ 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. 
  11. ^ 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. 
  12. ^ 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. 
  13. ^ 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. 
  14. ^ 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. 
  15. ^ 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)
  16. ^ 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. 
  17. ^ 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. 
  18. ^ 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. 
  19. ^ 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. 
  20. ^ 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. 
  21. ^ 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. 
  22. ^ 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. 
  23. ^ a b c Wilder 2016, p. 82.
  24. ^ 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. 
  25. ^ 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. 
  26. ^ a b c d McNeill 2015, p. 77.
  27. ^ a b McNeill 2015, p. 77-78.
  28. ^ 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)
  29. ^ 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. 
  30. ^ 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. 
  31. ^ 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. 
  32. ^ 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. 
  33. ^ 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. 
  34. ^ 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. 
  35. ^ 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. 
  36. ^ 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. 
  37. ^ 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. 
  38. ^ a b c d e f "Electronic Cigarettes – An Overview" (PDF). German Cancer Research Center. 2013. 
  39. ^ 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. 
  40. ^ 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. 
  41. ^ 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. 
  42. ^ "E-Cigarettes". Tobacco Control Research Branch of the National Cancer Institute. 
  43. ^ "Stop smoking treatments". UK National Health Service. 25 July 2014. 
  44. ^ "Standards of Medical Care in Diabetes--2015: Summary of Revisions". Diabetes Care. 54 (38): S25. 2015. doi:10.2337/dc15-S003. PMID 25537706. 
  45. ^ &NA; (August 2014). "E-Cigarettes". Oncology Times. 36 (15): 49–50. doi:10.1097/01.COT.0000453432.31465.77. 
  46. ^ "Nicotine addiction". Health Canada. 7 March 2013. 
  47. ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016. 
  48. ^ Detailed reference list is located at a separate image page.
  49. ^ McNeill 2015, p. 76.
  50. ^ 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. 
  51. ^ "RCP statement on e-cigarettes". Royal College of Physicians. 25 June 2014. 
  52. ^ 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. 
  53. ^ 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. 
  54. ^ "What about electronic cigarettes? Aren’t they safe?". American Cancer Society. 
  55. ^ "Ways to quit". Canadian Cancer Society. 2016. 
  56. ^ "Nicotine products can help people to cut down before quitting smoking". National Institute for Health and Care Excellence. June 2013. 
  57. ^ "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original (PDF) on 6 November 2014. 
  58. ^ 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. 
  59. ^ Detailed reference list is located at a separate image page.
  60. ^ 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. 
  61. ^ 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. 
  62. ^ 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)
  63. ^ 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. 
  64. ^ 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. 
  65. ^ 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. 
  66. ^ 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. 
  67. ^ 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. 
  68. ^ Detailed reference list is located at a separate image page.
  69. ^ 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. 
  70. ^ 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. 
  71. ^ 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. 
  72. ^ a b McNeill 2015, p. 63.
  73. ^ 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)
  74. ^ 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. 
  75. ^ 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. 
  76. ^ 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. 
  77. ^ "Poison Center Calls Involving E-Cigarettes". CDC. 14 April 2016. 
  78. ^ "Electronic Cigarettes and Liquid Nicotine Data" (PDF). American Association of Poison Control Centers. Retrieved 9 January 2016. 
  79. ^ 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. 
  80. ^ 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. 
  81. ^ 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. 
  82. ^ 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. 
  83. ^ 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. 
  84. ^ 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. 
  85. ^ 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. 
  86. ^ 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. 
  87. ^ 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. 
  88. ^ 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. 
  89. ^ "E-Cigarette Poisonings Among Toddlers Skyrocketed 1500% Over 3 Years". Yahoo! News. 9 May 2016. 
  90. ^ a b McNeill 2015, p. 67–68.
  91. ^ "Electronic cigarettes". Therapeutic Goods Administration. 
  92. ^ 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. 
  93. ^ 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. 
  94. ^ a b c d Bart Jansen (23 January 2015). "Packing e-Cigarettes in luggage is a fire risk, FAA warns". USA Today. 
  95. ^ McNeill 2015, p. 43-46.
  96. ^ McNeill 2015, p. 83-84.
  97. ^ a b Ashley Hasley III (26 January 2015). "The FAA wants you to carry on your e-Cigs". The Washington Post. 
  98. ^ 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. 
  99. ^ a b "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). Cancer Research UK. May 2014. 
  100. ^ 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. 
  101. ^ 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. 
  102. ^ Wilder 2016, p. 87.
  103. ^ "E-cigarettes to be regulated as medicines". National Health Service. 12 June 2013. Retrieved 1 August 2013. 
  104. ^ "WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems". World Medical Association. 
  105. ^ 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. 
  106. ^ 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. 
  107. ^ a b c d e "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. 
  108. ^ 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. 
  109. ^ 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. 
  110. ^ 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)
  111. ^ 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. 
  112. ^ 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. 
  113. ^ 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. 
  114. ^ 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. 
  115. ^ 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. 
  116. ^ 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. 
  117. ^ Detailed reference list is located at a separate image page.
  118. ^ 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. 
  119. ^ 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. 
  120. ^ 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. 
  121. ^ 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. 
  122. ^ a b c d e Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (01): 060–065. doi:10.1055/s-0033-1363468. ISSN 0094-6176. PMID 24343348. 
  123. ^ a b c d Nowak D, Jörres RA, Rüther T (2014). "E-cigarettes--prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. doi:10.3238/arztebl.2014.0349. PMC 4047602 . PMID 24882626. CS1 maint: Uses authors parameter (link)
  124. ^ Schroeder, M. J.; Hoffman, A. C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. doi:10.1136/tobaccocontrol-2013-051469. ISSN 0964-4563. PMC 3995273 . PMID 24732160. 
  125. ^ FDA (4 May 2009). "FDA 2009 Study Data: Evaluation of e-cigarettes" (PDF). Food and Drug Administration (US) -center for drug evaluation and research. Retrieved 4 May 2009. 
  126. ^ Golub, Justin S.; Samy, Ravi N. (2015). "Preventing or reducing smoking-related complications in otologic and neurotologic surgery". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (5): 334–340. doi:10.1097/MOO.0000000000000184. ISSN 1068-9508. PMID 26339963. 
  127. ^ Morris, Pamela B.; Ference, Brian A.; Jahangir, Eiman; Feldman, Dmitriy N.; Ryan, John J.; Bahrami, Hossein; El-Chami, Mikhael F.; Bhakta, Shyam; Winchester, David E.; Al-Mallah, Mouaz H.; Sanchez Shields, Monica; Deedwania, Prakash; Mehta, Laxmi S.; Phan, Binh An P.; Benowitz, Neal L. (2015). "Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes". Journal of the American College of Cardiology. 66 (12): 1378–1391. doi:10.1016/j.jacc.2015.07.037. ISSN 0735-1097. PMID 26383726. 
  128. ^ "People who want to quit smoking should consult their GP". Faculty of Public Health. 
  129. ^ a b Kleinstreuer, Clement; Feng, Yu (2013). "Lung Deposition Analyses of Inhaled Toxic Aerosols in Conventional and Less Harmful Cigarette Smoke: A Review". International Journal of Environmental Research and Public Health. 10 (9): 4454–4485. doi:10.3390/ijerph10094454. ISSN 1660-4601. PMC 3799535 . PMID 24065038. 
  130. ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013. p. 8. 
  131. ^ "Position Statement Electronic Cigarettes". Cancer Council Australia, Heart Foundation of Australia. 
  132. ^ a b Nelluri, Bhargava; Murphy, Katie; Mookadam, Farouk; Mookadam, Martina (2016). "The current literature regarding the cardiovascular effects of electronic cigarettes". Future Cardiology. 12 (2): 167–179. doi:10.2217/fca.15.83. ISSN 1479-6678. PMID 26916427. 
  133. ^ "White Paper: Electronic Cigarettes in the Indoor Environment" (PDF). American Industrial Hygiene Association. 19 October 2014. 
  134. ^ Chaffee, Benjamin W.; Couch, Elizabeth T.; Ryder, Mark I. (2016). "The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management". Periodontology 2000. 71 (1): 52–64. doi:10.1111/prd.12120. ISSN 0906-6713. PMC 4842013 . PMID 27045430. 
  135. ^ Offermann, Francis (June 2014). "The Hazards of E-Cigarettes" (PDF). ASHRAE Journal. 56 (6). 
  136. ^ "Backgrounder on WHO report on regulation of e-cigarettes and similar products". 26 August 2014. Retrieved 2 June 2015. 
  137. ^ John Reid Blackwell. "Avail Vapor offers glimpse into the 'art and science' of e-liquids". Richmond Times-Dispatch. Retrieved 2015-11-23. 
  138. ^ Products, Center for Tobacco. "Products, Guidance & Regulations - Deeming – Extending Authorities to Additional Tobacco Products". www.fda.gov. Archived from the original on 2014-04-26. Retrieved 2015-11-23. 
  139. ^ E-Liquid Manufacturing Standards (PDF). US: AMERICAN E-LIQUID MANUFACTURING STANDARDS ASSOCIATION (AEMSA). 2015. pp. 1–13. 
  140. ^ a b c d e f g h Holbrook, Bradley D. (2016). "The effects of nicotine on human fetal development". Birth Defects Research Part C: Embryo Today: Reviews. 108 (2): 181–192. doi:10.1002/bdrc.21128. ISSN 1542-975X. PMID 27297020. 
  141. ^ "Electronic Nicotine Delivery Systems (ENDS), including E-cigarettes". New Zealand Ministry of Health. 
  142. ^ Kaur, J.; Rinkoo, A. V. (2014). "A call for an urgent ban on E-cigarettes in India--a race against time". Global Health Promotion. 22 (2): 71–74. doi:10.1177/1757975914537322. ISSN 1757-9759. PMID 24938513. 
  143. ^ Suter, Melissa A.; Mastrobattista, Joan; Sachs, Maike; Aagaard, Kjersti (2015). "Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (3): 186–195. doi:10.1002/bdra.23333. ISSN 1542-0752. PMC 4830434 . PMID 25366492. 
  144. ^ a b c Brian Clark Howard (11 April 2012). "Cigarettes vs. e-Cigarettes: Which Is Less Environmentally Harmful?". National Geographic. 
  145. ^ Carroll Chapman, SL; Wu, LT (18 Mar 2014). "E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.". Journal of Psychiatric Research. 54: 43–54. doi:10.1016/j.jpsychires.2014.03.005. PMC 4055566 . PMID 24680203. 
  146. ^ Tomashefski, Amy (2016). "The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review". Journal of the American Association of Nurse Practitioners: n/a–n/a. doi:10.1002/2327-6924.12358. ISSN 2327-6886. PMID 26997487. 
  147. ^ a b c "Electronic cigarette use among smokers slows as perceptions of harm increase". ASH. 22 May 2015. Retrieved 6 August 2015. 
  148. ^ McNeill 2015, p. 79.
  149. ^ McNeill 2015, p. 6, 11, 79-80.
Smoking Vapor Electronic Cigarette

2017 Beyond the Data -- E-cigarettes: An Emerging Public Health Challenge

 UK

The entering into force of the requirements of the European tobacco products directive in Estonia made e-cigarette seller Nicorex Baltic destroy 19,000 bottles of e-cigarette liquid worth €135 000, as the packaging size did not meet the new requirements.

The liquids were actually in order, had undergone laboratory testing and met the new requirements, but their packaging did not have the necessary warnings on them and the boxes did not contain instructions.

Nicorex said that the transition period allowed by the government was too short, as the shelf life of the liquids was two years, but the length of the transition period only one year.

At the same time, Nicorex welcomed the requirement that the liquids have to undergo laboratory testing and that both the equipment and liquids must be registered in a single European database.

Nicorex described the restrictions concerning the size of packaging as unreasonable, as they increased the ecological footprint.

The transition period under the new tobacco law arising from the European tobacco products directive will end on May 20, after which the stricter requirements will apply to e-cigarettes in full.

Liquids can't be sold in containers bigger than 10 ml, they can't contain more nicotine than 20 milligrams per milliliter, and the vaporizer can't be bigger than 2 ml.

The packaging needs to include a leaflet, instructions, a batch number, a date, and a warning that nicotine is an addictive substance.


 

Uk E Liquid Free Delivery UK

Best Uk Vape Liquid UK

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.

Electronic Cigarette Health Risks

UK Electronic Cigarettes and E-Liquid

  (Redirected from Health effects of electronic cigarettes)

The safety of electronic cigarettes is uncertain.[1][2][3] There is little data about their safety, and considerable variability among e-cigarettes and in their liquid ingredients[4] and thus the contents of the aerosol delivered to the user.[5] Reviews on the safety of e-cigarettes have reached significantly different conclusions.[6] A 2014 World Health Organization (WHO) report cautioned about potential risks of using e-cigarettes.[7] Regulated US Food and Drug Administration (FDA) products such as nicotine inhalers are likely safer than e-cigarettes,.[8] 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.[9][10][11] However, e-cigarettes cannot be considered harmless.[12]

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.[3][13] The long-term effects of e-cigarette use are unknown.[13][14][15] 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.[16] Less serious adverse effects may include abdominal pain, headache, blurry vision,[16] throat and mouth irritation, vomiting, nausea, and coughing.[5] A 2014 WHO report said, "ENDS [electronic nicotine delivery system] use poses serious threats to adolescents and fetuses."[7] Aside from toxicity exposure in normal use, there are also risks from misuse or accidents[9] such as nicotine poisoning (especially among infants and children),[17] contact with liquid nicotine,[18] fires caused by vaporizer malfunction,[5] and explosions resulting from extended charging, unsuitable chargers, or design flaws.[9] Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns.[1] There is a small risk of battery explosion in devices modified to increase battery power.[19]

The cytotoxicity of e-liquids varies,[20] and contamination with various chemicals have been detected in the liquid.[21] Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals.[9] 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.[22] Normal usage of e-cigarettes,[23] and reduced voltage (3.0 V[24]) devices generate very low levels of formaldehyde.[22] Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[14][Notes 1] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[25] A 2015 Public Health England (PHE) report found that high levels of formaldehyde only occurred in overheated "dry-puffing".[26] 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."[27] However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.[19] E-cigarette users who use devices that contain nicotine are exposed to its potentially harmful effects.[24] Nicotine is associated with cardiovascular disease, potential birth defects, and poisoning.[28]In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo.[28] There is inadequate research to demonstrate that nicotine is associated with cancer in humans.[29] The risk is probably low from the inhalation of propylene glycol and glycerin.[13] No information is available on the long-term effects of the inhalation of flavors.[21]

E-cigarettes create an aerosol that consists of fine and ultrafine particles of particulate matter, with the majority of particles in the ultrafine range.[5][30] 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.[5][13] Exactly what the vapor comprises varies in composition and concentration across and within manufacturers.[24] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.[31] The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor.[9] E-cigarette vapor contains lower concentrations of potentially toxic chemicals than with cigarette smoke.[32] Those which are present, are mostly below 1% the corresponding levels permissible by workplace safety standards.[33] 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.[5] Concern exists that some of the mainstream vapor exhaled by e-cigarette users may be inhaled by bystanders, particularly indoors.[34] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[35] A 2014 review recommended that e-cigarettes should be regulated for consumer safety.[36] There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges.[37]

Reviews on the safety of e-cigarettes, evaluating roughly the same studies, have reached significantly different conclusions.[6] Due to various methodological issues, severe conflicts of interest, and inconsistent research, no definite conclusions can be determined regarding the safety of e-cigarettes.[12] However, e-cigarettes cannot be regarded as harmless.[12] There is little data about their safety, and considerable variability among vaporizers and in their liquid ingredients[4] and thus the contents of the aerosol delivered to the user.[5] 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.[36] 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.[38] 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."[17] 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.[7]

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.[39] A 2014 review recommended that e-cigarettes could be adequately regulated for consumer safety with existing regulations on the design of electronic products.[36] Regulation of the production and promotion of e-cigarettes may help lower some adverse effects associated with tobacco use.[34] 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.[40] 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.[40] The industry could also lead vapers to tobacco products, which would increase instead of decrease overall addiction.[40]

The health effects related to e-cigarette use is mostly unknown.[41] The health effects on intensive e-cigarette users are unknown.[14] The effect on population health from e-cigarettes is unknown.[8] 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."[42] 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."[43] The American Diabetes Association states "There is no evidence that e-cigarettes are a healthier alternative to smoking."[44] In August 2014, the Forum of International Respiratory Societies stated that e-cigarettes have not been demonstrated to be safe.[45]Health Canada has stated that, "their safety, quality, and efficacy remain unknown."[46] 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."[47]

Effects of vaping, compared to tobacco smoking.[48]

A 2015 Public Health England (PHE) report stated that e-cigarettes are estimated to be 95% less harmful than smoking,[49] although this estimate has been disputed.[50] 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."[51] 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.[9] 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.[52] Scientific studies advocate caution before designating e-cigarettes as beneficial but vapers continue to believe they are beneficial.[53]

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."[54] 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."[55] 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.[56] 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."[57] No long-term studies have evaluated future tobacco use as a result of e-cigarette use.[58] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.[31]

Possible adverse effects of vaping.[59]

As of 2015, the short-term and long-term effects from using e-cigarettes remain unclear.[14]Adverse effects are mostly associated with short-term use and the reported adverse effects decreased over time.[60] Long-term studies regarding the effects of constant use of e-cigarettes are unavailable.[60] The adverse effects of e-cigarettes on people with cancer is unknown.[17] A 2014 Cochrane review found no serious adverse effects reported in trials,[61] but serious events have been reported in case studies.[13]

The evidence suggests they produce less harmful effects than combusted tobacco.[11] 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.[53] Many health benefits are associated with switching from tobacco to e-cigarettes including decreased weight gain after smoking cessation and improved exercise tolerance.[62] 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.[63] Many people use e-cigarettes to quit smoking, but few succeed.[64] They frequently use both, which increases their health risks by using both products.[64] Quitting smoking entirely would probably have much greater beneficial effects to overall health than vaping to decrease the number of cigarettes smoked.[5]

More serious adverse effects frequently related with smoking cessation including depression, insomnia, and anxiety are uncommon with e-cigarette use.[16] 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.[16] Less serious adverse effects include abdominal pain, headache, blurry vision,[16] throat and mouth irritation, vomiting, nausea, and coughing.[5] Short-term adverse effects reported most often were mouth and throat irritation, dry cough, and nausea.[60] The majority of adverse effects reported were nausea, vomiting, dizziness and oral irritation.[9] 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.[22] 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.[17]

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.[13] 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.[41] The man from the UK reportedly died from severe lipoid pneumonia in 2011.[41] Reports to the Food and Drug Administration (FDA) for minor adverse effects identified with using e-cigarettes include headache, chest pain, nausea, and cough.[1] Major adverse effects reported to the FDA included hospitalizations for pneumonia, congestive heart failure, seizure, rapid heart rate, and burns.[1] 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.[1] 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.[65] 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.[66] E-cigarettes were associated with fewer adverse effects than nicotine patches.[67]

Symptoms of nicotine poisoning related to e-cigarette calls to US poison control centers.[68]

Nicotine poisoning related to e-cigarettes include ingestion, inhalation, or absorption via the skin or eyes.[17] Accidental poisoning can result from using undiluted concentrated nicotine when mistakenly used as prepared e-liquids.[69] E-cigarettes involve accidental nicotine exposure in children.[18] Accidental exposures in pediatric patients include ingesting of e-liquids and inhaling of e-cigarette vapors.[18] Choking on e-cigarette components is a potential risk.[18] It is recommended that youth access to e-cigarettes be prohibited.[70]

Four adults died in the US and Europe, after intentionally ingesting liquid.[41] Two children, one in the US in 2014 and another in Israel in 2013, died after ingesting liquid nicotine.[71] Death from accidental nicotine poisoning is very uncommon.[72]

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.[73] Minor, moderate, and serious adverse effects involved adults and young children.[74] Minor effects correlated with e-cigarette liquid poisoning were tachycardia, tremor, chest pain and hypertension.[75] More serious effects were bradycardia, hypotension, nausea, respiratory paralysis, atrial fibrillation and dyspnea.[75] The exact correlation is not fully known between these effects and e-cigarettes.[75] 58% of e-cigarette calls to US poison control centers were related to children 5 years old or less.[74] 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.[74] Most of the e-cigarette and traditional cigarette calls were a minor effect.[74] Severe outcomes were more than 2.5 times more frequent in children exposed to e-cigarettes and nicotine e-liquid than with traditional cigarettes.[76] 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%.[74]

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.[77]

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;[74] inhalation/nasal exposure resulted in nausea, vomiting, dizziness, agitated, or headache;[74] ocular exposure resulted in eye irritation or pain, red eye or conjunctivitis, blurred vision, headache, or corneal abrasion;[74] multiple routes of exposure resulted in eye irritation or pain, vomiting, red eye or conjunctivitis, nausea, or cough;[74] and dermal exposure that resulted in nausea, dizziness, vomiting, headache, or tachycardia.[74] 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%).[74] In nine reported calls, exposed individuals stated the device leaked.[74] In five reported calls, individuals used e-liquid for their eyes rather than use eye drops.[74] In one reported call, an infant was given the e-liquid by an adult who thought it was the infant's medication.[74] There were also reports of choking on e-cigarette components.[18]

From January 1, 2016 and April 30, 2016, the American Association of Poison Control Centers (AAPCC) reported 623 exposures related to e-cigarettes.[64] The AAPCC reported 3,067 exposures relating to e-cigarettes and liquid nicotine in 2015, and 3,783 in 2014.[78] From September 1, 2010 to December 31, 2014, there were at least 5,970 e-cigarette calls to US poison control centers.[74] 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%.[67] 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.[75] E-cigarette calls was 401 for the month of April 2014.[74] 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.[9]

Fruit flavored e-liquids.

There is a possibility that inhalation, ingestion, or skin contact can expose people to high levels of nicotine.[34] Concerns with exposure to the e-liquids include leaks or spills and contact with contaminants in the e-liquid.[79] This may be especially risky to children, pregnant women, and nursing mothers.[34] The liquid quickly absorbs into the skin.[80] The nicotine in e-liquid can be hazardous to infants.[81] Even a portion of e-liquid may be lethal to a little child.[82] An excessive amount of nicotine for a child that is capable of being fatal is 0.1–0.2 mg/kg of body weight.[34] Less than a 1 tablespoon of contact or ingestion of e-liquid can cause nausea, vomiting, cardiac arrest, seizures, or coma.[83] An accidental ingestion of only 6 mg may be lethal to children.[38][84]

Children are susceptible to ingestion due to their curiosity and desire for oral exploration.[76] E-cigarettes are packed in colorful containers[74] and children may be attracted to the flavored liquids.[58] More youth-oriented flavors include "My Birthday Cake" or "Tutti Frutti Gumballs".[71] Many nicotine cartridges and bottles of liquid are not child-resistant to stop contact or accidental ingestion of nicotine by children.[11] "Open" e-cigarette devices, with a refillable tank for e-liquids, are believed to be the biggest risk to young children.[83] It is recommended that e-cigarettes be kept in a safe place, where children and pets do not have access to them.[85]

Nicotine toxicity is of concern when e-cigarette solutions are swallowed intentionally by adults as a suicidal overdose.[40] Six people attempted suicide by injecting e-liquid.[41] One adolescent attempted suicide by swallowing the e-liquid.[18] Three deaths were reported to have resulted from swallowing or injecting e-liquid containing nicotine.[41] An excessive amount of nicotine for an adult that is capable of being fatal is 0.5–1 mg/kg of body weight.[34] An oral lethal dose for adults is about 30–60 mg.[53] 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.[86] Reports of serious adverse effects associated with acute nicotine toxicity that resulting in hospitalization were very uncommon.[87] Death from intentional nicotine poisoning is very uncommon.[72] Clear labeling of devices and e-liquid could reduce unintentional exposures.[74] Child-proof packaging and directions for safe handling of e-liquids could minimize some of the risks.[81] In January 2016, the Child Nicotine Poisoning Prevention Act of 2015 was passed into law in the US,[88] which requires child-proof packaging.[89]

There was inconsistent labeling of the actual nicotine content on e-liquid cartridges from some brands,[5] and some nicotine has been found in ‘no nicotine' liquids.[21] A 2015 PHE report noted overall the labelling accuracy has improved.[90] Most inaccurately-labelled examples contained less nicotine than stated.[90] Due to nicotine content inconstancy, it is recommended that e-cigarette companies develop quality standards with respect to nicotine content.[24]

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.[81] 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.[38] This includes leaking cartridges, accidental contact with nicotine when changing cartridges, and potential of unintended overdose.[38] 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."[91]

Cannabinoid-containing e-liquids need lengthy, complex processing, some being available online without any toxicological and clinical evaluation.[92] 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.[92] The health effects of vaping cannabis formulations is mostly unknown.[92]

Most e-cigarettes use lithium batteries, the improper use of which may result in accidents.[9] It has been recommended that manufacturing quality standards be imposed in order to prevent such accidents.[9] Better product design and standards could probably reduce some of the risks.[79] Concern exists from risks associated with e-cigarette explosions for children and adults.[18]

Some batteries are not well designed, are made with poor quality components, or have defects.[1] Major injuries have occurred from battery explosions and fires.[5] 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.[93] A young man endured bilateral corneal burns to the eye area when an e-cigarette exploded near his chest.[93] E-cigarette explosions have resulted in burns, lost teeth, neck fractures, and battery acid contact to the face, mouth, and eyes.[93] A man died when charging an e-cigarette blown up and caught on fire next to oxygen equipment.[93] House and car fires and skin burns have resulted from some of the explosions.[1] The explosions were the result of extended charging, use of unsuitable chargers, or design flaws.[9] There is a possible risk to bystanders from e-cigarette explosions.[93] There is also a risk of property damage as a result of flammable materials catching on fire from an e-cigarette explosion.[93] The United States Fire Administration said that 25 fires and explosions were caused by e-cigarettes between 2009 and August 2014.[94] In the UK fire service call-outs had risen, from 43 in 2013 to 62 in 2014.[95] A 2015 PHE report concluded that the risks of fire from e-cigarettes "appear to be comparable to similar electrical goods".[96] 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.[93] There is inadequate product labeling to inform users of the possible serious harms.[93] The risk from serious adverse effects is low, but the aftermath may be disastrous in respect to an e-cigarette blast.[93] Victims have filed lawsuits to make restitution from the e-cigarette blasts.[41] Adverse effects may be under-reported because reports to the FDA is voluntary.[93]

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.[94][97] The International Civil Aviation Organization, a United Nations agency, also recommends prohibiting e-cigarettes in checked luggage.[94] 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.[94] In-flight use of e-cigarettes is prohibited in the US.[97]

Users may alter many of the devices, such as using them to administer other drugs like cannabis.[5] E-liquid mixing is another way users tamper with e-cigarettes.[98] Mixing liquid in an unclean area runs the risk of contamination.[16] Users may add various flavorings and diluents.[98] Vodka or other forms of alcohol may also be added.[98] The addition of alcohol or nicotine could expose the user to more toxicants, especially when added in combinations.[98] 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.[98] Users can adjust the voltage of some e-cigarettes.[98] 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.[19] Some users add more or larger batteries to nonadjustable e-cigarettes, which may lead to battery leakage or explosion.[98] 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.[18]

The long-term health impacts of e-cigarette use are unknown.[13] The long-term health impacts of the main chemicals nicotine and propylene glycol in the aerosol are not fully understood.[99] There is limited peer-reviewed data about the toxicity of e-cigarettes for a complete toxicological evaluation,[100] and their cytotoxicity is unknown.[15] The chemicals and toxicants included in e-cigarettes have not been completely disclosed and their safety is not guaranteed.[34] They are similar in toxicity to other nicotine replacement products,[101] but e-cigarettes manufacturing standards are variable standards, and many as a result are probably more toxic than nicotine replacement products.[102] 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.[103] 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.[36]

Concerns about the carcinogenicity of e-cigarettes arise from both nicotine[28] and from other chemicals that may be in the vapor.[24] 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.[28] 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".[29] 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".[29] Nicotine in the form of nicotine replacement products is less of a risk than compared to smoking,[29] and they have not been shown to be associated with cancer in the real world.[28]

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.[8] 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."[99] The e-cigarette vapors triggered DNA strand breaks and lowered cell survival in vitro.[41] 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.[10] 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."[104]

Chart showing various toxicants as measured in cigarette smoke and e-cigarette aerosol.[105]

Since nicotine-containing e-liquids are made from tobacco they may contain impurities like cotinine, anabasine, anatabine, myosmine and beta-nicotyrine.[13] The majority of e-cigarettes evaluated included carcinogenic tobacco-specific nitrosamines (TSNAs); heavy metals such as cadmium, nickel, and lead; and the carcinogen toluene.[34] However, in comparison to traditional cigarette smoke, the toxic substance levels identified in e-cigarette vapor were 9- to 450-fold less.[34] E-liquid with tin was cytotoxic.[12] E-cigarettes cannot be considered absolutely safe because there is no safe level for carcinogens.[106]

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.[8] 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."[107]

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."[24] Few of the methods used to analyze the chemistry of e-cigarettes in the studies the review evaluated were validated.[24]

The propylene glycol molecule.

The primary base ingredients of the liquid solution is propylene glycol and glycerin.[5] About 20% to 27% of propylene glycol and glycerin-based liquid particles are inhaled.[108] The long-term effects of inhaled propylene glycol has not been studied,[58] and is unknown.[109] The effects of inhaled glycerin are unknown.[84] Being exposed to propylene glycol may cause irritation to the eyes and respiratory tract.[5] The risk from the inhalation of propylene glycol and glycerin is probably low.[13] Propylene glycol and glycerin have not been shown to be safe.[84] Some research states that propylene glycol emissions may cause respiratory irritation and raise the likelihood to develop asthma.[52] Long-term inhalation of propylene glycol indoors could increase risk to children to develop asthma.[38] To lessen the risks, most e-cigarettes companies began to use water and glycerin as replacement for propylene glycol.[52] The inhaled glycerin could cause lipoid pneumonia.[16]

Some e-cigarette products had acrolein identified in the aerosol.[13] It may be generated when glycerin is heated to higher temperatures.[13] Acrolein may induce irritation to the upper respiratory tract.[5] Acrolein levels were reduced by 60% in dual users and 80% for those that completely switched to e-cigarettes when compared to traditional cigarettes.[13] E-cigarettes vapor have been found to create oxidants and reactive oxygen species (OX/ROS).[19] OX/ROS could react with other substances in the vapor because they are highly reactive.[19] 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.[19]

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.[100] 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.[33] The short-term toxicity of e-cigarette use appears to be low, with the exception for some people with reactive airways.[21]

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.[21] The cytotoxicity of e-liquids varies,[20] and contamination with various chemicals have been detected in the liquid.[21] Some liquids were very toxic and others had little or no cytotoxicity.[20] The cytotoxicity is mostly due to the amount and number of flavors added.[20] Since nicotine has a bitter taste, nicotine e-liquids contain chemicals to cover up the nicotine taste.[19] The liquids contain aromatic substances like tobacco, fruit, vanilla, caramel and coffee.[21] Generally, these additives are imprecisely described, using terms such as "vegetable flavoring".[21] Although they are approved for human consumption there are no studies on the short-term or long-term effects of inhaling them.[21] The safety of inhaling flavors is mostly unknown,[110] and their safety has not been determined by the Flavor and Extract Manufacturers Association.[41] In some cases e-liquids contain very large amounts of flavorings, which may cause irritation and inflammation on respiratory and cardiovascular systems.[69] Some flavors are regarded as toxic and a number of them resemble known carcinogens.[21] Some artificial flavors are known to be cytotoxic.[21] Unflavored vapor is less cytotoxic than flavored vapor.[23] 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.[111]

Cinnamaldehyde has been described as a highly cytotoxic material in vitro in cinnamon-flavored refill liquids.[1] 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.[9] Some e-liquids containing cinnamaldehyde stimulate TRPA1, which might induce effects on the lung.[19] E-liquids contain possibly toxic aldehydes and reactive oxygen species (ROS).[19] Many flavors are known aldehydes, such as anisaldehyde, cinnamaldehyde, and isovaleraldehyde.[19] The effects of aldehyde-containing flavors on pulmonary surfaces are unknown.[19] A 2012 study found butterscotch flavor was highly toxic with one liquid and two others had a low toxicity.[40] 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.[34] Some additives may be added to reduce the irritation on the pharynx.[84] The long-term toxicity is subject to the additives and contaminants in the e-liquid.[21]

Certain flavorings contain diacetyl and acetyl propionyl which give a buttery taste.[31] Diacetyl and acetyl propionyl are associated with bronchiolitis obliterans.[31] 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.[6] Both diacetyl and acetyl-propionyl have been found in concentrations above those recommended by the US National Institute for Occupational Safety and Health.[31] Diacetyl is normally found at lower levels in e-cigarettes than in traditional cigarettes.[31] Concerns exist that the flavors and additives in e-cigarettes might lead to diseases, including the popcorn lung.[112] The cardiovascular effects, including a vast range of flavorings and fragrances, is unknown.[113] 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.[62] The precise ingredients of e-cigarettes are not known.[114]

The IARC has categorized formaldehyde as a human carcinogen, and acetaldehyde is categorized as a potential carcinogenic to humans.[22] Aldehydes may cause harmful health effects; though, in the majority of cases, the amounts inhaled are less than with traditional cigarettes.[22] 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,[22] to high temperatures.[34] These compounds are frequently identified in e-cigarette aerosols.[22] The propylene glycol-containing liquids produced the most amounts of carbonyls in e-cigarette aerosols.[22] 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.[5] Nearly all e-cigarettes evaluated, toxic and irritation-causing carbonyls were identified.[34] Reports regarding the levels of toxic chemicals were inconsistent.[34] This includes a study showing that the levels of toxicants in e-cigarettes may be higher than with cigarette smoke.[34]

Battery output voltage influences the level of the carbonyl substances in the vapor.[22] A few new e-cigarettes let users boost the amount of vapor and nicotine provided by modifying the battery output voltage.[22] E-cigarettes with higher voltages (5.0 V[20]) can emit carcinogens including formaldehyde at levels comparable to cigarette smoke,[115] while reduced voltages (3.0 V[24]) generate aerosol with levels of formaldehyde and acetaldehyde roughly 13 and 807-fold less than in cigarette smoke.[22] "Dripping", where the liquid is dripped directly onto the atomizer, can create carbonyls including formaldehyde.[116]

A 2015 PHE report found that normal e-cigarette use generates very low levels of aldehydes.[26] Normal usage of e-cigarettes generates very low levels of formaldehyde,[23] and at normal settings they generate very low levels of formaldehyde.[26] Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[14][Notes 2] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[25] 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.[26] 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."[27] However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.[19]

Possible side effects of nicotine.[117] 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.[118] Shown above is the MOE for daily drug use from the analysis.[118]

Pregnant women, breastfeeding mothers, and the elderly are more sensitive to nicotine than other individuals.[110] There are safety issues with the nicotine exposure from e-cigarettes, which may cause addiction and other adverse effects.[24] Nicotine is regarded as a potentially lethal poison.[17] Concerns exist that vaping can be harmful by exposing users to toxic levels of nicotine.[17] At low amounts, it has a mild analgesic effect.[110] At high enough doses, nicotine may result in nausea, vomiting, diarrhea, salivation, bradyarrhythmia, and possibly seizures and hypoventilation.[35] 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.[17] The health effects of nicotine in infants and children are unclear.[35]

E-cigarettes provide nicotine to the blood quicker than nicotine inhalers.[53] The levels were above that of nicotine replacement product users.[17] E-cigarettes seem to have a pharmacokinetic nicotine profile closer to nicotine replacement products than with traditional cigarettes.[119] How efficiently different e-cigarettes give nicotine is unclear.[17]Serum cotinine levels are comparable to that of traditional cigarettes,[120] but are inharmonious and rely upon the user and the device.[8] Blood nicotine levels raised more gradually and took more time to get to peak concentration with e-cigarettes than with traditional cigarettes.[121]

When compared to traditional cigarettes older devices usually delivered low amounts of nicotine.[17] 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.[122] This is due to the minute nicotine particles in the vapor, which permit quick delivery into the bloodstream.[122] The nicotine delivered from e-cigarettes enters the body slower than traditional cigarettes.[123] Studies suggest that inexperienced users obtain moderate amounts of nicotine from e-cigarettes.[124] Concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device.[125]

Later-generation e-cigarettes gives nicotine more effectively than first-generation e-cigarettes.[1] Later-generation models with concentrated nicotine liquids may deliver nicotine at levels similar to traditional cigarettes.[17] E-cigarettes with stronger batteries heat solutions to higher temperatures, which may raise blood nicotine levels to those of traditional cigarettes.[40] Research suggests that experienced e-cigarettes users are able to get as much nicotine from e-cigarettes as traditional cigarettes.[17] Later-generation e-cigarettes containing sufficient nicotine elevates heart rate comparable to traditional cigarettes.[113]

The health effects of long-term nicotine use is unknown.[109] It may be decades before the long-term health effects of nicotine vapor inhalation is known.[126] It is not recommended for non-smokers.[9] Nicotine affects practically every cell in the body.[110] Nicotine can cause high blood pressure and abnormal heart rhythms.[107] Vapers that get a higher amount of blood nicotine are probably correlated with increased heart rates.[87] Nicotine may have adverse effects on lipids,[127] cause insulin resistance.[40] and can lower coronary blood flow.[113] Nicotine lowers estrogen levels and has been associated with early menopause in women.[107] Nicotine could have cancer-promoting properties, therefore long-term use may not be harmless.[98] Nicotine may result in neuroplasticity variations in the brain.[80] Nicotine could make cancer therapies less effective.[16]

Children are more sensitive to nicotine than adults.[110] In youth, nicotine may affect capabilities connected with higher cognitive function processes,[35] later achievement, as well as the chance of nicotine addiction for life.[107] The adolescents developing brain is especially sensitive to the harmful effects of nicotine.[82] A short period of regular or occasional nicotine exposure in adolescence exerts long-term neurobehavioral damage.[82] In August 2014, the American Heart Association noted that "e-cigarettes could fuel and promote nicotine addiction, especially in children."[40] 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."[128]

There is limited evidence on the long-term exposure of metals.[9] Exposure to the levels and kinds of metals found in the aerosol relies upon the material and other manufacturing designs of the heating element.[40] 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.[9] The device itself could contribute to the toxicity from the tiny amounts of silicate and heavy metals found in the liquid and vapor,[116] because they have metal parts that come in contact with the e-liquid.[9] Low levels of possibly harmful chromium, lead, and nickel metals have been found in the emissions.[40] Chromium and nickel nanoparticles have also been found.[5]

Metals may adversely affect the nervous system.[70] A 2013 review found metallic and nanoparticles are associated with respiratory distress and disease.[129] 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.[34] A 2013 study found metal particles in the aerosol were at levels 10-50 times less than permitted in inhalation medicines.[13] A 2014 review suggested that there is no evidence of contamination of the aerosol with metals that justifies a health concern.[33]

Abbreviations: μg, microgram; ng, nanogram; ND, not detected.[20]
∗Fifteen puffs were chosen to estimate the nicotine delivery of one traditional cigarette.[20]

The risks to the lungs are not fully understood,[19] and concern exists regarding the negative effects on lung function.[130] There is limited evidence on the long-term health effects to the lungs.[14] Many ingredients used in e-liquids have not been examined in the lung.[19] The effects of e-cigarette use in respect to asthma and other respiratory diseases are unknown.[13] A 2015 review found e-cigarettes may induce acute lung disease.[14] A 2015 study found that e-cigarette vapors can induce oxidative stress in lung endothelial cells.[69] 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.[41] The limited evidence suggests that e-cigarettes produce less short-term effects on lung function than traditional cigarettes.[8] A 2014 case report observed the correlation between sub-acute bronchiolitis and vaping.[14] After quitting vaping the symptoms improved.[14]

The long-term effects regarding respiratory flow resistance are unknown.[60] E-cigarettes could harm the respiratory system.[21] The immediate effects of e-cigarettes after 5 minutes of use on pulmonary function resulted in considerable increases in resistance to lung airflow.[1] A 2013 review found an instant increase in airway resistance after using a single e-cigarette.[21] Any reported harmful effects to cardiovascular and respiratory functions after short-term use of e-cigarettes were appreciably milder in comparison to cigarette smoke.[9] When used in the short-term, an e-cigarette resulted in a rise of respiratory resistance comparatively to traditional cigarettes.[60] E-cigarette use could result in respiratory diseases among youth.[131]

There is no data available on the long-term cardiovascular effects.[8] There is no published research available on vaping and thrombosis, platelet reactivity, atherosclerosis, or blood vessel function.[14] 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.[122] Some case reports documented the possible cardiovascular adverse effects from using e-cigarettes, the majority associated was with improper use.[122] 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.[122] E-cigarette use leads to sympathomimetic effects because of nicotine intake.[132] It is argued that there could be a risk for harmful effects, including tachycardia-induced cardiomyopathy.[132] E-cigarettes containing nicotine may have a lower cardiovascular effect than traditional cigarettes containing nicotine.[113] Short-term physiological effects include increases in blood pressure and heart rate.[14] A 2012 case report found a correlation between paroxysmal atrial fibrillation and vaping.[14]

Comparable to a traditional cigarette, e-cigarette particles are tiny enough to enter the alveoli, enabling nicotine absorption.[1] These particles are also tiny enough to go deep in the lungs and enter into the systemic circulation.[5] Local pulmonary toxicity may occur because metal nanoparticles can deposit in the lung's alveolar sacs.[5] E-cigarettes companies assert that the particulates produced by an e-cigarette are too tiny to be deposited in the alveoli.[53] Different devices generate different particle sizes and cause different depositions in the respiratory tract, even from the same nicotine liquid.[115] The aerosol production of e-cigarettes during vaping decreases, which requires a more forceful suction to create a similar volume of aerosol.[66] A more forceful suction could affect the deposition of substances into the lungs.[66] Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern.[133]

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.[87] There were reports of e-cigarettes causing an immune system reaction involving inflammation of the gastrointestinal system.[41] Long-term use could increase the risk of tuberculosis.[12] It is possible that e-cigarettes could harm the periodontium because of the effects of nicotine on gum tissues and the immune system.[134] 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.[87]

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.[19] The user inhales the aerosol, commonly called vapor, rather than cigarette smoke.[24] 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.[24] The aerosol is made-up of liquid sub-micron particles of condensed vapor,[135] which mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and other chemicals.[9] After a puff, inhalation of the aerosol travels from the device into the mouth and lungs.[24] 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.[5]

Various bottles of e-liquid.

After the aerosol is inhaled, it is exhaled.[24] Emissions from electronic cigarettes are not comparable to environmental pollution or cigarette smoke as their nature and chemical composition are completely different[9] The particles are larger, with the mean size being 600 nm in inhaled aerosol and 300 nm in exhaled vapor.[21] Bystanders are exposed to these particles from exhaled e-cigarette vapor.[5] 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.[34][129] Since e-cigarettes involve an aerosolization process, it is suggested that no meaningful amounts of carbon monoxide are emitted.[123] Thus, cardiocirculatory effects caused by carbon monoxide are not likely.[123] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[35] E-cigarettes pose many safety concerns to children.[35] 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.[35]

E-liquid is the mixture used in vapor products such as electronic cigarettes.[52] The main ingredients in the e-liquid usually are propylene glycol, glycerin, nicotine, and flavorings.[101] However, there are e-liquids sold without propylene glycol, nicotine, or flavors.[17][52][61] The liquid typically contains 95% propylene glycol and glycerin.[84] The flavorings may be natural or artificial.[21] About 8,000 flavors exist as of 2014.[136] There are many e-liquids manufacturers in the USA and worldwide.[137] 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.[138] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).[139]

Concerns exists regarding pregnant women exposure to e-cigarette vapor through direct use or via exhaled vapor.[5] No evidence have shown that e-cigarettes are safe to use for pregnant women.[140] No amount of nicotine is safe for pregnant women.[140] 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.[8] E-cigarette are assumed to be dangerous to the fetus during pregnancy if e-cigarettes are used by the mother.[141] Nicotine is harmful to the growing fetus.[142] Nicotine accumulates in the fetus because it goes through the placenta.[38]

As of 2015[update], the long-term issues of e-cigarettes on both mother and unborn baby are unknown.[143] 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.[140] Prenatal nicotine exposure is associated with lower birth weights than other babies,[140]stillbirth,[82]sudden infant death syndrome, and alterations to normal brain development.[140] Prenatal nicotine exposure is associated with asthma and wheezing which may continue into adulthood.[140]Gestational age nicotine exposure is associated with many neurological deficits.[140] Prenatal exposure has been associated with obesity, diabetes, high cholesterol and high blood pressure in minors.[107] Prenatal nicotine exposure in females may lead toward early menarche.[140] An infant was born with necrotizing enterocolitis due to e-cigarette use during pregnancy.[41]

In what way the e-liquid ingredients could affect a fetus is unknown.[2] 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.[109] There are concerns about the health impacts of pediatric exposure to second-hand and third-hand e-cigarette vapor.[18] 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."[17] The belief that e-cigarettes are safer than traditional cigarettes could increase their use in pregnant women.[1] The toxic effects identified with e-cigarette refill liquids on stem cells may be interpreted as embryonic death or birth defects.[1] 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.[35] There is concern for breastfeeding women using e-cigarettes, due to the lack of data on propylene glycol transferring to breastmilk.[21]

There is limited information available on any environmental issues connected to the production, usage, and disposal of e-cigarette models that use cartridges.[37] 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.[37] 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.[37] It is not clear which manufacturing methods are used to make the nicotine used in e-cigarettes.[37] The emissions from making nicotine could be considerable from manufacturing if not appropriately controlled.[37] Some e-cigarette brands that use cartridges state their products are ‘eco-friendly’ or ‘green’, despite the absence of any supporting studies.[37] Some writers contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors.[37]

It is unclear how many traditional cigarettes are comparable to using one e-cigarette that uses a cartridge for the average user.[37] Information is limited on energy and materials used for production of e-cigarettes versus traditional cigarettes, for comparable use.[37] E-cigarettes can be made manually put together in small factories, or they can be made in automated lines on a much bigger scale.[37] Larger plants will produce greater emissions to the surrounding environment, and thus will have a greater environmental impact.[37] 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.[37] A 2014 review found "disposable e-cigarettes might cause an electrical waste problem."[123] Since the majority of e-cigarettes are reusable they are possibly more environmentally friendly than using single-use devices.[144] Compared to traditional cigarettes, e-cigarettes do not create litter in the form of discarded cigarette butts.[144] Traditional cigarette tend to end up in the ocean where they cause pollution.[144]

Marketing and advertisement affects the public’s perception of e-cigarettes.[109] Some tobacco users think vaping is safer than tobacco or other smoking cessation aids.[145] It is generally considered by users that e-cigarettes are safer than tobacco.[114] Many users think that e-cigarettes are healthier than traditional cigarettes for personal use or for other people.[58] Usually, only a small proportion of users are concerned about the possible adverse health effects or toxicity of e-cigarettes.[58] 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.[146] A 2013 four-country survey found higher than 75% of current and former smokers think e-cigarettes are safer than traditional cigarettes.[1] 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".[147] 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."[147] 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."[147]

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.[148] 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?][149]

  1. ^ 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. 
  2. ^ 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. 
  3. ^ 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. 
  4. ^ 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. 
  5. ^ 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. 
  6. ^ 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. 
  7. ^ a b c "Electronic nicotine delivery systems" (PDF). WHO. pp. 1–13. Retrieved 28 August 2014. 
  8. ^ 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. 
  9. ^ 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. 
  10. ^ 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. 
  11. ^ 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. 
  12. ^ 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. 
  13. ^ 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. 
  14. ^ 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. 
  15. ^ 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)
  16. ^ 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. 
  17. ^ 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. 
  18. ^ 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. 
  19. ^ 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. 
  20. ^ 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. 
  21. ^ 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. 
  22. ^ 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. 
  23. ^ a b c Wilder 2016, p. 82.
  24. ^ 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. 
  25. ^ 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. 
  26. ^ a b c d McNeill 2015, p. 77.
  27. ^ a b McNeill 2015, p. 77-78.
  28. ^ 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)
  29. ^ 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. 
  30. ^ 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. 
  31. ^ 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. 
  32. ^ 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. 
  33. ^ 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. 
  34. ^ 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. 
  35. ^ 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. 
  36. ^ 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. 
  37. ^ 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. 
  38. ^ a b c d e f "Electronic Cigarettes – An Overview" (PDF). German Cancer Research Center. 2013. 
  39. ^ 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. 
  40. ^ 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. 
  41. ^ 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. 
  42. ^ "E-Cigarettes". Tobacco Control Research Branch of the National Cancer Institute. 
  43. ^ "Stop smoking treatments". UK National Health Service. 25 July 2014. 
  44. ^ "Standards of Medical Care in Diabetes--2015: Summary of Revisions". Diabetes Care. 54 (38): S25. 2015. doi:10.2337/dc15-S003. PMID 25537706. 
  45. ^ &NA; (August 2014). "E-Cigarettes". Oncology Times. 36 (15): 49–50. doi:10.1097/01.COT.0000453432.31465.77. 
  46. ^ "Nicotine addiction". Health Canada. 7 March 2013. 
  47. ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016. 
  48. ^ Detailed reference list is located at a separate image page.
  49. ^ McNeill 2015, p. 76.
  50. ^ 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. 
  51. ^ "RCP statement on e-cigarettes". Royal College of Physicians. 25 June 2014. 
  52. ^ 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. 
  53. ^ 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. 
  54. ^ "What about electronic cigarettes? Aren’t they safe?". American Cancer Society. 
  55. ^ "Ways to quit". Canadian Cancer Society. 2016. 
  56. ^ "Nicotine products can help people to cut down before quitting smoking". National Institute for Health and Care Excellence. June 2013. 
  57. ^ "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original (PDF) on 6 November 2014. 
  58. ^ 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. 
  59. ^ Detailed reference list is located at a separate image page.
  60. ^ 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. 
  61. ^ 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. 
  62. ^ 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)
  63. ^ 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. 
  64. ^ 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. 
  65. ^ 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. 
  66. ^ 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. 
  67. ^ 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. 
  68. ^ Detailed reference list is located at a separate image page.
  69. ^ 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. 
  70. ^ 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. 
  71. ^ 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. 
  72. ^ a b McNeill 2015, p. 63.
  73. ^ 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)
  74. ^ 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. 
  75. ^ 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. 
  76. ^ 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. 
  77. ^ "Poison Center Calls Involving E-Cigarettes". CDC. 14 April 2016. 
  78. ^ "Electronic Cigarettes and Liquid Nicotine Data" (PDF). American Association of Poison Control Centers. Retrieved 9 January 2016. 
  79. ^ 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. 
  80. ^ 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. 
  81. ^ 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. 
  82. ^ 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. 
  83. ^ 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. 
  84. ^ 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. 
  85. ^ 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. 
  86. ^ 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. 
  87. ^ 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. 
  88. ^ 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. 
  89. ^ "E-Cigarette Poisonings Among Toddlers Skyrocketed 1500% Over 3 Years". Yahoo! News. 9 May 2016. 
  90. ^ a b McNeill 2015, p. 67–68.
  91. ^ "Electronic cigarettes". Therapeutic Goods Administration. 
  92. ^ 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. 
  93. ^ 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. 
  94. ^ a b c d Bart Jansen (23 January 2015). "Packing e-Cigarettes in luggage is a fire risk, FAA warns". USA Today. 
  95. ^ McNeill 2015, p. 43-46.
  96. ^ McNeill 2015, p. 83-84.
  97. ^ a b Ashley Hasley III (26 January 2015). "The FAA wants you to carry on your e-Cigs". The Washington Post. 
  98. ^ 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. 
  99. ^ a b "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). Cancer Research UK. May 2014. 
  100. ^ 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. 
  101. ^ 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. 
  102. ^ Wilder 2016, p. 87.
  103. ^ "E-cigarettes to be regulated as medicines". National Health Service. 12 June 2013. Retrieved 1 August 2013. 
  104. ^ "WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems". World Medical Association. 
  105. ^ 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. 
  106. ^ 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. 
  107. ^ a b c d e "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. 
  108. ^ 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. 
  109. ^ 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. 
  110. ^ 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)
  111. ^ 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. 
  112. ^ 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. 
  113. ^ 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. 
  114. ^ 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. 
  115. ^ 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. 
  116. ^ 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. 
  117. ^ Detailed reference list is located at a separate image page.
  118. ^ 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. 
  119. ^ 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. 
  120. ^ 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. 
  121. ^ 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. 
  122. ^ a b c d e Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (01): 060–065. doi:10.1055/s-0033-1363468. ISSN 0094-6176. PMID 24343348. 
  123. ^ a b c d Nowak D, Jörres RA, Rüther T (2014). "E-cigarettes--prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. doi:10.3238/arztebl.2014.0349. PMC 4047602 . PMID 24882626. CS1 maint: Uses authors parameter (link)
  124. ^ Schroeder, M. J.; Hoffman, A. C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. doi:10.1136/tobaccocontrol-2013-051469. ISSN 0964-4563. PMC 3995273 . PMID 24732160. 
  125. ^ FDA (4 May 2009). "FDA 2009 Study Data: Evaluation of e-cigarettes" (PDF). Food and Drug Administration (US) -center for drug evaluation and research. Retrieved 4 May 2009. 
  126. ^ Golub, Justin S.; Samy, Ravi N. (2015). "Preventing or reducing smoking-related complications in otologic and neurotologic surgery". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (5): 334–340. doi:10.1097/MOO.0000000000000184. ISSN 1068-9508. PMID 26339963. 
  127. ^ Morris, Pamela B.; Ference, Brian A.; Jahangir, Eiman; Feldman, Dmitriy N.; Ryan, John J.; Bahrami, Hossein; El-Chami, Mikhael F.; Bhakta, Shyam; Winchester, David E.; Al-Mallah, Mouaz H.; Sanchez Shields, Monica; Deedwania, Prakash; Mehta, Laxmi S.; Phan, Binh An P.; Benowitz, Neal L. (2015). "Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes". Journal of the American College of Cardiology. 66 (12): 1378–1391. doi:10.1016/j.jacc.2015.07.037. ISSN 0735-1097. PMID 26383726. 
  128. ^ "People who want to quit smoking should consult their GP". Faculty of Public Health. 
  129. ^ a b Kleinstreuer, Clement; Feng, Yu (2013). "Lung Deposition Analyses of Inhaled Toxic Aerosols in Conventional and Less Harmful Cigarette Smoke: A Review". International Journal of Environmental Research and Public Health. 10 (9): 4454–4485. doi:10.3390/ijerph10094454. ISSN 1660-4601. PMC 3799535 . PMID 24065038. 
  130. ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013. p. 8. 
  131. ^ "Position Statement Electronic Cigarettes". Cancer Council Australia, Heart Foundation of Australia. 
  132. ^ a b Nelluri, Bhargava; Murphy, Katie; Mookadam, Farouk; Mookadam, Martina (2016). "The current literature regarding the cardiovascular effects of electronic cigarettes". Future Cardiology. 12 (2): 167–179. doi:10.2217/fca.15.83. ISSN 1479-6678. PMID 26916427. 
  133. ^ "White Paper: Electronic Cigarettes in the Indoor Environment" (PDF). American Industrial Hygiene Association. 19 October 2014. 
  134. ^ Chaffee, Benjamin W.; Couch, Elizabeth T.; Ryder, Mark I. (2016). "The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management". Periodontology 2000. 71 (1): 52–64. doi:10.1111/prd.12120. ISSN 0906-6713. PMC 4842013 . PMID 27045430. 
  135. ^ Offermann, Francis (June 2014). "The Hazards of E-Cigarettes" (PDF). ASHRAE Journal. 56 (6). 
  136. ^ "Backgrounder on WHO report on regulation of e-cigarettes and similar products". 26 August 2014. Retrieved 2 June 2015. 
  137. ^ John Reid Blackwell. "Avail Vapor offers glimpse into the 'art and science' of e-liquids". Richmond Times-Dispatch. Retrieved 2015-11-23. 
  138. ^ Products, Center for Tobacco. "Products, Guidance & Regulations - Deeming – Extending Authorities to Additional Tobacco Products". www.fda.gov. Archived from the original on 2014-04-26. Retrieved 2015-11-23. 
  139. ^ E-Liquid Manufacturing Standards (PDF). US: AMERICAN E-LIQUID MANUFACTURING STANDARDS ASSOCIATION (AEMSA). 2015. pp. 1–13. 
  140. ^ a b c d e f g h Holbrook, Bradley D. (2016). "The effects of nicotine on human fetal development". Birth Defects Research Part C: Embryo Today: Reviews. 108 (2): 181–192. doi:10.1002/bdrc.21128. ISSN 1542-975X. PMID 27297020. 
  141. ^ "Electronic Nicotine Delivery Systems (ENDS), including E-cigarettes". New Zealand Ministry of Health. 
  142. ^ Kaur, J.; Rinkoo, A. V. (2014). "A call for an urgent ban on E-cigarettes in India--a race against time". Global Health Promotion. 22 (2): 71–74. doi:10.1177/1757975914537322. ISSN 1757-9759. PMID 24938513. 
  143. ^ Suter, Melissa A.; Mastrobattista, Joan; Sachs, Maike; Aagaard, Kjersti (2015). "Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (3): 186–195. doi:10.1002/bdra.23333. ISSN 1542-0752. PMC 4830434 . PMID 25366492. 
  144. ^ a b c Brian Clark Howard (11 April 2012). "Cigarettes vs. e-Cigarettes: Which Is Less Environmentally Harmful?". National Geographic. 
  145. ^ Carroll Chapman, SL; Wu, LT (18 Mar 2014). "E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.". Journal of Psychiatric Research. 54: 43–54. doi:10.1016/j.jpsychires.2014.03.005. PMC 4055566 . PMID 24680203. 
  146. ^ Tomashefski, Amy (2016). "The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review". Journal of the American Association of Nurse Practitioners: n/a–n/a. doi:10.1002/2327-6924.12358. ISSN 2327-6886. PMID 26997487. 
  147. ^ a b c "Electronic cigarette use among smokers slows as perceptions of harm increase". ASH. 22 May 2015. Retrieved 6 August 2015. 
  148. ^ McNeill 2015, p. 79.
  149. ^ McNeill 2015, p. 6, 11, 79-80.
E Cigarette Electronic

Electronic cigarette

 UK   (Redirected from Health effects of electronic cigarettes)

The safety of electronic cigarettes is uncertain.[1][2][3] There is little data about their safety, and considerable variability among e-cigarettes and in their liquid ingredients[4] and thus the contents of the aerosol delivered to the user.[5] Reviews on the safety of e-cigarettes have reached significantly different conclusions.[6] A 2014 World Health Organization (WHO) report cautioned about potential risks of using e-cigarettes.[7] Regulated US Food and Drug Administration (FDA) products such as nicotine inhalers are likely safer than e-cigarettes,.[8] 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.[9][10][11] However, e-cigarettes cannot be considered harmless.[12]

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.[3][13] The long-term effects of e-cigarette use are unknown.[13][14][15] 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.[16] Less serious adverse effects may include abdominal pain, headache, blurry vision,[16] throat and mouth irritation, vomiting, nausea, and coughing.[5] A 2014 WHO report said, "ENDS [electronic nicotine delivery system] use poses serious threats to adolescents and fetuses."[7] Aside from toxicity exposure in normal use, there are also risks from misuse or accidents[9] such as nicotine poisoning (especially among infants and children),[17] contact with liquid nicotine,[18] fires caused by vaporizer malfunction,[5] and explosions resulting from extended charging, unsuitable chargers, or design flaws.[9] Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns.[1] There is a small risk of battery explosion in devices modified to increase battery power.[19]

The cytotoxicity of e-liquids varies,[20] and contamination with various chemicals have been detected in the liquid.[21] Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals.[9] 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.[22] Normal usage of e-cigarettes,[23] and reduced voltage (3.0 V[24]) devices generate very low levels of formaldehyde.[22] Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[14][Notes 1] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[25] A 2015 Public Health England (PHE) report found that high levels of formaldehyde only occurred in overheated "dry-puffing".[26] 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."[27] However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.[19] E-cigarette users who use devices that contain nicotine are exposed to its potentially harmful effects.[24] Nicotine is associated with cardiovascular disease, potential birth defects, and poisoning.[28]In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo.[28] There is inadequate research to demonstrate that nicotine is associated with cancer in humans.[29] The risk is probably low from the inhalation of propylene glycol and glycerin.[13] No information is available on the long-term effects of the inhalation of flavors.[21]

E-cigarettes create an aerosol that consists of fine and ultrafine particles of particulate matter, with the majority of particles in the ultrafine range.[5][30] 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.[5][13] Exactly what the vapor comprises varies in composition and concentration across and within manufacturers.[24] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.[31] The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor.[9] E-cigarette vapor contains lower concentrations of potentially toxic chemicals than with cigarette smoke.[32] Those which are present, are mostly below 1% the corresponding levels permissible by workplace safety standards.[33] 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.[5] Concern exists that some of the mainstream vapor exhaled by e-cigarette users may be inhaled by bystanders, particularly indoors.[34] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[35] A 2014 review recommended that e-cigarettes should be regulated for consumer safety.[36] There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges.[37]

Reviews on the safety of e-cigarettes, evaluating roughly the same studies, have reached significantly different conclusions.[6] Due to various methodological issues, severe conflicts of interest, and inconsistent research, no definite conclusions can be determined regarding the safety of e-cigarettes.[12] However, e-cigarettes cannot be regarded as harmless.[12] There is little data about their safety, and considerable variability among vaporizers and in their liquid ingredients[4] and thus the contents of the aerosol delivered to the user.[5] 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.[36] 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.[38] 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."[17] 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.[7]

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.[39] A 2014 review recommended that e-cigarettes could be adequately regulated for consumer safety with existing regulations on the design of electronic products.[36] Regulation of the production and promotion of e-cigarettes may help lower some adverse effects associated with tobacco use.[34] 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.[40] 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.[40] The industry could also lead vapers to tobacco products, which would increase instead of decrease overall addiction.[40]

The health effects related to e-cigarette use is mostly unknown.[41] The health effects on intensive e-cigarette users are unknown.[14] The effect on population health from e-cigarettes is unknown.[8] 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."[42] 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."[43] The American Diabetes Association states "There is no evidence that e-cigarettes are a healthier alternative to smoking."[44] In August 2014, the Forum of International Respiratory Societies stated that e-cigarettes have not been demonstrated to be safe.[45]Health Canada has stated that, "their safety, quality, and efficacy remain unknown."[46] 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."[47]

Effects of vaping, compared to tobacco smoking.[48]

A 2015 Public Health England (PHE) report stated that e-cigarettes are estimated to be 95% less harmful than smoking,[49] although this estimate has been disputed.[50] 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."[51] 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.[9] 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.[52] Scientific studies advocate caution before designating e-cigarettes as beneficial but vapers continue to believe they are beneficial.[53]

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."[54] 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."[55] 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.[56] 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."[57] No long-term studies have evaluated future tobacco use as a result of e-cigarette use.[58] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke.[31]

Possible adverse effects of vaping.[59]

As of 2015, the short-term and long-term effects from using e-cigarettes remain unclear.[14]Adverse effects are mostly associated with short-term use and the reported adverse effects decreased over time.[60] Long-term studies regarding the effects of constant use of e-cigarettes are unavailable.[60] The adverse effects of e-cigarettes on people with cancer is unknown.[17] A 2014 Cochrane review found no serious adverse effects reported in trials,[61] but serious events have been reported in case studies.[13]

The evidence suggests they produce less harmful effects than combusted tobacco.[11] 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.[53] Many health benefits are associated with switching from tobacco to e-cigarettes including decreased weight gain after smoking cessation and improved exercise tolerance.[62] 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.[63] Many people use e-cigarettes to quit smoking, but few succeed.[64] They frequently use both, which increases their health risks by using both products.[64] Quitting smoking entirely would probably have much greater beneficial effects to overall health than vaping to decrease the number of cigarettes smoked.[5]

More serious adverse effects frequently related with smoking cessation including depression, insomnia, and anxiety are uncommon with e-cigarette use.[16] 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.[16] Less serious adverse effects include abdominal pain, headache, blurry vision,[16] throat and mouth irritation, vomiting, nausea, and coughing.[5] Short-term adverse effects reported most often were mouth and throat irritation, dry cough, and nausea.[60] The majority of adverse effects reported were nausea, vomiting, dizziness and oral irritation.[9] 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.[22] 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.[17]

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.[13] 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.[41] The man from the UK reportedly died from severe lipoid pneumonia in 2011.[41] Reports to the Food and Drug Administration (FDA) for minor adverse effects identified with using e-cigarettes include headache, chest pain, nausea, and cough.[1] Major adverse effects reported to the FDA included hospitalizations for pneumonia, congestive heart failure, seizure, rapid heart rate, and burns.[1] 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.[1] 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.[65] 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.[66] E-cigarettes were associated with fewer adverse effects than nicotine patches.[67]

Symptoms of nicotine poisoning related to e-cigarette calls to US poison control centers.[68]

Nicotine poisoning related to e-cigarettes include ingestion, inhalation, or absorption via the skin or eyes.[17] Accidental poisoning can result from using undiluted concentrated nicotine when mistakenly used as prepared e-liquids.[69] E-cigarettes involve accidental nicotine exposure in children.[18] Accidental exposures in pediatric patients include ingesting of e-liquids and inhaling of e-cigarette vapors.[18] Choking on e-cigarette components is a potential risk.[18] It is recommended that youth access to e-cigarettes be prohibited.[70]

Four adults died in the US and Europe, after intentionally ingesting liquid.[41] Two children, one in the US in 2014 and another in Israel in 2013, died after ingesting liquid nicotine.[71] Death from accidental nicotine poisoning is very uncommon.[72]

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.[73] Minor, moderate, and serious adverse effects involved adults and young children.[74] Minor effects correlated with e-cigarette liquid poisoning were tachycardia, tremor, chest pain and hypertension.[75] More serious effects were bradycardia, hypotension, nausea, respiratory paralysis, atrial fibrillation and dyspnea.[75] The exact correlation is not fully known between these effects and e-cigarettes.[75] 58% of e-cigarette calls to US poison control centers were related to children 5 years old or less.[74] 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.[74] Most of the e-cigarette and traditional cigarette calls were a minor effect.[74] Severe outcomes were more than 2.5 times more frequent in children exposed to e-cigarettes and nicotine e-liquid than with traditional cigarettes.[76] 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%.[74]

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.[77]

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;[74] inhalation/nasal exposure resulted in nausea, vomiting, dizziness, agitated, or headache;[74] ocular exposure resulted in eye irritation or pain, red eye or conjunctivitis, blurred vision, headache, or corneal abrasion;[74] multiple routes of exposure resulted in eye irritation or pain, vomiting, red eye or conjunctivitis, nausea, or cough;[74] and dermal exposure that resulted in nausea, dizziness, vomiting, headache, or tachycardia.[74] 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%).[74] In nine reported calls, exposed individuals stated the device leaked.[74] In five reported calls, individuals used e-liquid for their eyes rather than use eye drops.[74] In one reported call, an infant was given the e-liquid by an adult who thought it was the infant's medication.[74] There were also reports of choking on e-cigarette components.[18]

From January 1, 2016 and April 30, 2016, the American Association of Poison Control Centers (AAPCC) reported 623 exposures related to e-cigarettes.[64] The AAPCC reported 3,067 exposures relating to e-cigarettes and liquid nicotine in 2015, and 3,783 in 2014.[78] From September 1, 2010 to December 31, 2014, there were at least 5,970 e-cigarette calls to US poison control centers.[74] 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%.[67] 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.[75] E-cigarette calls was 401 for the month of April 2014.[74] 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.[9]

Fruit flavored e-liquids.

There is a possibility that inhalation, ingestion, or skin contact can expose people to high levels of nicotine.[34] Concerns with exposure to the e-liquids include leaks or spills and contact with contaminants in the e-liquid.[79] This may be especially risky to children, pregnant women, and nursing mothers.[34] The liquid quickly absorbs into the skin.[80] The nicotine in e-liquid can be hazardous to infants.[81] Even a portion of e-liquid may be lethal to a little child.[82] An excessive amount of nicotine for a child that is capable of being fatal is 0.1–0.2 mg/kg of body weight.[34] Less than a 1 tablespoon of contact or ingestion of e-liquid can cause nausea, vomiting, cardiac arrest, seizures, or coma.[83] An accidental ingestion of only 6 mg may be lethal to children.[38][84]

Children are susceptible to ingestion due to their curiosity and desire for oral exploration.[76] E-cigarettes are packed in colorful containers[74] and children may be attracted to the flavored liquids.[58] More youth-oriented flavors include "My Birthday Cake" or "Tutti Frutti Gumballs".[71] Many nicotine cartridges and bottles of liquid are not child-resistant to stop contact or accidental ingestion of nicotine by children.[11] "Open" e-cigarette devices, with a refillable tank for e-liquids, are believed to be the biggest risk to young children.[83] It is recommended that e-cigarettes be kept in a safe place, where children and pets do not have access to them.[85]

Nicotine toxicity is of concern when e-cigarette solutions are swallowed intentionally by adults as a suicidal overdose.[40] Six people attempted suicide by injecting e-liquid.[41] One adolescent attempted suicide by swallowing the e-liquid.[18] Three deaths were reported to have resulted from swallowing or injecting e-liquid containing nicotine.[41] An excessive amount of nicotine for an adult that is capable of being fatal is 0.5–1 mg/kg of body weight.[34] An oral lethal dose for adults is about 30–60 mg.[53] 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.[86] Reports of serious adverse effects associated with acute nicotine toxicity that resulting in hospitalization were very uncommon.[87] Death from intentional nicotine poisoning is very uncommon.[72] Clear labeling of devices and e-liquid could reduce unintentional exposures.[74] Child-proof packaging and directions for safe handling of e-liquids could minimize some of the risks.[81] In January 2016, the Child Nicotine Poisoning Prevention Act of 2015 was passed into law in the US,[88] which requires child-proof packaging.[89]

There was inconsistent labeling of the actual nicotine content on e-liquid cartridges from some brands,[5] and some nicotine has been found in ‘no nicotine' liquids.[21] A 2015 PHE report noted overall the labelling accuracy has improved.[90] Most inaccurately-labelled examples contained less nicotine than stated.[90] Due to nicotine content inconstancy, it is recommended that e-cigarette companies develop quality standards with respect to nicotine content.[24]

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.[81] 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.[38] This includes leaking cartridges, accidental contact with nicotine when changing cartridges, and potential of unintended overdose.[38] 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."[91]

Cannabinoid-containing e-liquids need lengthy, complex processing, some being available online without any toxicological and clinical evaluation.[92] 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.[92] The health effects of vaping cannabis formulations is mostly unknown.[92]

Most e-cigarettes use lithium batteries, the improper use of which may result in accidents.[9] It has been recommended that manufacturing quality standards be imposed in order to prevent such accidents.[9] Better product design and standards could probably reduce some of the risks.[79] Concern exists from risks associated with e-cigarette explosions for children and adults.[18]

Some batteries are not well designed, are made with poor quality components, or have defects.[1] Major injuries have occurred from battery explosions and fires.[5] 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.[93] A young man endured bilateral corneal burns to the eye area when an e-cigarette exploded near his chest.[93] E-cigarette explosions have resulted in burns, lost teeth, neck fractures, and battery acid contact to the face, mouth, and eyes.[93] A man died when charging an e-cigarette blown up and caught on fire next to oxygen equipment.[93] House and car fires and skin burns have resulted from some of the explosions.[1] The explosions were the result of extended charging, use of unsuitable chargers, or design flaws.[9] There is a possible risk to bystanders from e-cigarette explosions.[93] There is also a risk of property damage as a result of flammable materials catching on fire from an e-cigarette explosion.[93] The United States Fire Administration said that 25 fires and explosions were caused by e-cigarettes between 2009 and August 2014.[94] In the UK fire service call-outs had risen, from 43 in 2013 to 62 in 2014.[95] A 2015 PHE report concluded that the risks of fire from e-cigarettes "appear to be comparable to similar electrical goods".[96] 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.[93] There is inadequate product labeling to inform users of the possible serious harms.[93] The risk from serious adverse effects is low, but the aftermath may be disastrous in respect to an e-cigarette blast.[93] Victims have filed lawsuits to make restitution from the e-cigarette blasts.[41] Adverse effects may be under-reported because reports to the FDA is voluntary.[93]

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.[94][97] The International Civil Aviation Organization, a United Nations agency, also recommends prohibiting e-cigarettes in checked luggage.[94] 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.[94] In-flight use of e-cigarettes is prohibited in the US.[97]

Users may alter many of the devices, such as using them to administer other drugs like cannabis.[5] E-liquid mixing is another way users tamper with e-cigarettes.[98] Mixing liquid in an unclean area runs the risk of contamination.[16] Users may add various flavorings and diluents.[98] Vodka or other forms of alcohol may also be added.[98] The addition of alcohol or nicotine could expose the user to more toxicants, especially when added in combinations.[98] 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.[98] Users can adjust the voltage of some e-cigarettes.[98] 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.[19] Some users add more or larger batteries to nonadjustable e-cigarettes, which may lead to battery leakage or explosion.[98] 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.[18]

The long-term health impacts of e-cigarette use are unknown.[13] The long-term health impacts of the main chemicals nicotine and propylene glycol in the aerosol are not fully understood.[99] There is limited peer-reviewed data about the toxicity of e-cigarettes for a complete toxicological evaluation,[100] and their cytotoxicity is unknown.[15] The chemicals and toxicants included in e-cigarettes have not been completely disclosed and their safety is not guaranteed.[34] They are similar in toxicity to other nicotine replacement products,[101] but e-cigarettes manufacturing standards are variable standards, and many as a result are probably more toxic than nicotine replacement products.[102] 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.[103] 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.[36]

Concerns about the carcinogenicity of e-cigarettes arise from both nicotine[28] and from other chemicals that may be in the vapor.[24] 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.[28] 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".[29] 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".[29] Nicotine in the form of nicotine replacement products is less of a risk than compared to smoking,[29] and they have not been shown to be associated with cancer in the real world.[28]

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.[8] 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."[99] The e-cigarette vapors triggered DNA strand breaks and lowered cell survival in vitro.[41] 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.[10] 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."[104]

Chart showing various toxicants as measured in cigarette smoke and e-cigarette aerosol.[105]

Since nicotine-containing e-liquids are made from tobacco they may contain impurities like cotinine, anabasine, anatabine, myosmine and beta-nicotyrine.[13] The majority of e-cigarettes evaluated included carcinogenic tobacco-specific nitrosamines (TSNAs); heavy metals such as cadmium, nickel, and lead; and the carcinogen toluene.[34] However, in comparison to traditional cigarette smoke, the toxic substance levels identified in e-cigarette vapor were 9- to 450-fold less.[34] E-liquid with tin was cytotoxic.[12] E-cigarettes cannot be considered absolutely safe because there is no safe level for carcinogens.[106]

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.[8] 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."[107]

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."[24] Few of the methods used to analyze the chemistry of e-cigarettes in the studies the review evaluated were validated.[24]

The propylene glycol molecule.

The primary base ingredients of the liquid solution is propylene glycol and glycerin.[5] About 20% to 27% of propylene glycol and glycerin-based liquid particles are inhaled.[108] The long-term effects of inhaled propylene glycol has not been studied,[58] and is unknown.[109] The effects of inhaled glycerin are unknown.[84] Being exposed to propylene glycol may cause irritation to the eyes and respiratory tract.[5] The risk from the inhalation of propylene glycol and glycerin is probably low.[13] Propylene glycol and glycerin have not been shown to be safe.[84] Some research states that propylene glycol emissions may cause respiratory irritation and raise the likelihood to develop asthma.[52] Long-term inhalation of propylene glycol indoors could increase risk to children to develop asthma.[38] To lessen the risks, most e-cigarettes companies began to use water and glycerin as replacement for propylene glycol.[52] The inhaled glycerin could cause lipoid pneumonia.[16]

Some e-cigarette products had acrolein identified in the aerosol.[13] It may be generated when glycerin is heated to higher temperatures.[13] Acrolein may induce irritation to the upper respiratory tract.[5] Acrolein levels were reduced by 60% in dual users and 80% for those that completely switched to e-cigarettes when compared to traditional cigarettes.[13] E-cigarettes vapor have been found to create oxidants and reactive oxygen species (OX/ROS).[19] OX/ROS could react with other substances in the vapor because they are highly reactive.[19] 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.[19]

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.[100] 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.[33] The short-term toxicity of e-cigarette use appears to be low, with the exception for some people with reactive airways.[21]

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.[21] The cytotoxicity of e-liquids varies,[20] and contamination with various chemicals have been detected in the liquid.[21] Some liquids were very toxic and others had little or no cytotoxicity.[20] The cytotoxicity is mostly due to the amount and number of flavors added.[20] Since nicotine has a bitter taste, nicotine e-liquids contain chemicals to cover up the nicotine taste.[19] The liquids contain aromatic substances like tobacco, fruit, vanilla, caramel and coffee.[21] Generally, these additives are imprecisely described, using terms such as "vegetable flavoring".[21] Although they are approved for human consumption there are no studies on the short-term or long-term effects of inhaling them.[21] The safety of inhaling flavors is mostly unknown,[110] and their safety has not been determined by the Flavor and Extract Manufacturers Association.[41] In some cases e-liquids contain very large amounts of flavorings, which may cause irritation and inflammation on respiratory and cardiovascular systems.[69] Some flavors are regarded as toxic and a number of them resemble known carcinogens.[21] Some artificial flavors are known to be cytotoxic.[21] Unflavored vapor is less cytotoxic than flavored vapor.[23] 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.[111]

Cinnamaldehyde has been described as a highly cytotoxic material in vitro in cinnamon-flavored refill liquids.[1] 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.[9] Some e-liquids containing cinnamaldehyde stimulate TRPA1, which might induce effects on the lung.[19] E-liquids contain possibly toxic aldehydes and reactive oxygen species (ROS).[19] Many flavors are known aldehydes, such as anisaldehyde, cinnamaldehyde, and isovaleraldehyde.[19] The effects of aldehyde-containing flavors on pulmonary surfaces are unknown.[19] A 2012 study found butterscotch flavor was highly toxic with one liquid and two others had a low toxicity.[40] 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.[34] Some additives may be added to reduce the irritation on the pharynx.[84] The long-term toxicity is subject to the additives and contaminants in the e-liquid.[21]

Certain flavorings contain diacetyl and acetyl propionyl which give a buttery taste.[31] Diacetyl and acetyl propionyl are associated with bronchiolitis obliterans.[31] 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.[6] Both diacetyl and acetyl-propionyl have been found in concentrations above those recommended by the US National Institute for Occupational Safety and Health.[31] Diacetyl is normally found at lower levels in e-cigarettes than in traditional cigarettes.[31] Concerns exist that the flavors and additives in e-cigarettes might lead to diseases, including the popcorn lung.[112] The cardiovascular effects, including a vast range of flavorings and fragrances, is unknown.[113] 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.[62] The precise ingredients of e-cigarettes are not known.[114]

The IARC has categorized formaldehyde as a human carcinogen, and acetaldehyde is categorized as a potential carcinogenic to humans.[22] Aldehydes may cause harmful health effects; though, in the majority of cases, the amounts inhaled are less than with traditional cigarettes.[22] 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,[22] to high temperatures.[34] These compounds are frequently identified in e-cigarette aerosols.[22] The propylene glycol-containing liquids produced the most amounts of carbonyls in e-cigarette aerosols.[22] 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.[5] Nearly all e-cigarettes evaluated, toxic and irritation-causing carbonyls were identified.[34] Reports regarding the levels of toxic chemicals were inconsistent.[34] This includes a study showing that the levels of toxicants in e-cigarettes may be higher than with cigarette smoke.[34]

Battery output voltage influences the level of the carbonyl substances in the vapor.[22] A few new e-cigarettes let users boost the amount of vapor and nicotine provided by modifying the battery output voltage.[22] E-cigarettes with higher voltages (5.0 V[20]) can emit carcinogens including formaldehyde at levels comparable to cigarette smoke,[115] while reduced voltages (3.0 V[24]) generate aerosol with levels of formaldehyde and acetaldehyde roughly 13 and 807-fold less than in cigarette smoke.[22] "Dripping", where the liquid is dripped directly onto the atomizer, can create carbonyls including formaldehyde.[116]

A 2015 PHE report found that normal e-cigarette use generates very low levels of aldehydes.[26] Normal usage of e-cigarettes generates very low levels of formaldehyde,[23] and at normal settings they generate very low levels of formaldehyde.[26] Later-generation e-cigarettes used with higher power may generate equal or higher levels of formaldehyde than compared to smoking.[14][Notes 2] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[25] 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.[26] 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."[27] However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.[19]

Possible side effects of nicotine.[117] 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.[118] Shown above is the MOE for daily drug use from the analysis.[118]

Pregnant women, breastfeeding mothers, and the elderly are more sensitive to nicotine than other individuals.[110] There are safety issues with the nicotine exposure from e-cigarettes, which may cause addiction and other adverse effects.[24] Nicotine is regarded as a potentially lethal poison.[17] Concerns exist that vaping can be harmful by exposing users to toxic levels of nicotine.[17] At low amounts, it has a mild analgesic effect.[110] At high enough doses, nicotine may result in nausea, vomiting, diarrhea, salivation, bradyarrhythmia, and possibly seizures and hypoventilation.[35] 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.[17] The health effects of nicotine in infants and children are unclear.[35]

E-cigarettes provide nicotine to the blood quicker than nicotine inhalers.[53] The levels were above that of nicotine replacement product users.[17] E-cigarettes seem to have a pharmacokinetic nicotine profile closer to nicotine replacement products than with traditional cigarettes.[119] How efficiently different e-cigarettes give nicotine is unclear.[17]Serum cotinine levels are comparable to that of traditional cigarettes,[120] but are inharmonious and rely upon the user and the device.[8] Blood nicotine levels raised more gradually and took more time to get to peak concentration with e-cigarettes than with traditional cigarettes.[121]

When compared to traditional cigarettes older devices usually delivered low amounts of nicotine.[17] 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.[122] This is due to the minute nicotine particles in the vapor, which permit quick delivery into the bloodstream.[122] The nicotine delivered from e-cigarettes enters the body slower than traditional cigarettes.[123] Studies suggest that inexperienced users obtain moderate amounts of nicotine from e-cigarettes.[124] Concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device.[125]

Later-generation e-cigarettes gives nicotine more effectively than first-generation e-cigarettes.[1] Later-generation models with concentrated nicotine liquids may deliver nicotine at levels similar to traditional cigarettes.[17] E-cigarettes with stronger batteries heat solutions to higher temperatures, which may raise blood nicotine levels to those of traditional cigarettes.[40] Research suggests that experienced e-cigarettes users are able to get as much nicotine from e-cigarettes as traditional cigarettes.[17] Later-generation e-cigarettes containing sufficient nicotine elevates heart rate comparable to traditional cigarettes.[113]

The health effects of long-term nicotine use is unknown.[109] It may be decades before the long-term health effects of nicotine vapor inhalation is known.[126] It is not recommended for non-smokers.[9] Nicotine affects practically every cell in the body.[110] Nicotine can cause high blood pressure and abnormal heart rhythms.[107] Vapers that get a higher amount of blood nicotine are probably correlated with increased heart rates.[87] Nicotine may have adverse effects on lipids,[127] cause insulin resistance.[40] and can lower coronary blood flow.[113] Nicotine lowers estrogen levels and has been associated with early menopause in women.[107] Nicotine could have cancer-promoting properties, therefore long-term use may not be harmless.[98] Nicotine may result in neuroplasticity variations in the brain.[80] Nicotine could make cancer therapies less effective.[16]

Children are more sensitive to nicotine than adults.[110] In youth, nicotine may affect capabilities connected with higher cognitive function processes,[35] later achievement, as well as the chance of nicotine addiction for life.[107] The adolescents developing brain is especially sensitive to the harmful effects of nicotine.[82] A short period of regular or occasional nicotine exposure in adolescence exerts long-term neurobehavioral damage.[82] In August 2014, the American Heart Association noted that "e-cigarettes could fuel and promote nicotine addiction, especially in children."[40] 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."[128]

There is limited evidence on the long-term exposure of metals.[9] Exposure to the levels and kinds of metals found in the aerosol relies upon the material and other manufacturing designs of the heating element.[40] 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.[9] The device itself could contribute to the toxicity from the tiny amounts of silicate and heavy metals found in the liquid and vapor,[116] because they have metal parts that come in contact with the e-liquid.[9] Low levels of possibly harmful chromium, lead, and nickel metals have been found in the emissions.[40] Chromium and nickel nanoparticles have also been found.[5]

Metals may adversely affect the nervous system.[70] A 2013 review found metallic and nanoparticles are associated with respiratory distress and disease.[129] 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.[34] A 2013 study found metal particles in the aerosol were at levels 10-50 times less than permitted in inhalation medicines.[13] A 2014 review suggested that there is no evidence of contamination of the aerosol with metals that justifies a health concern.[33]

Abbreviations: μg, microgram; ng, nanogram; ND, not detected.[20]
∗Fifteen puffs were chosen to estimate the nicotine delivery of one traditional cigarette.[20]

The risks to the lungs are not fully understood,[19] and concern exists regarding the negative effects on lung function.[130] There is limited evidence on the long-term health effects to the lungs.[14] Many ingredients used in e-liquids have not been examined in the lung.[19] The effects of e-cigarette use in respect to asthma and other respiratory diseases are unknown.[13] A 2015 review found e-cigarettes may induce acute lung disease.[14] A 2015 study found that e-cigarette vapors can induce oxidative stress in lung endothelial cells.[69] 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.[41] The limited evidence suggests that e-cigarettes produce less short-term effects on lung function than traditional cigarettes.[8] A 2014 case report observed the correlation between sub-acute bronchiolitis and vaping.[14] After quitting vaping the symptoms improved.[14]

The long-term effects regarding respiratory flow resistance are unknown.[60] E-cigarettes could harm the respiratory system.[21] The immediate effects of e-cigarettes after 5 minutes of use on pulmonary function resulted in considerable increases in resistance to lung airflow.[1] A 2013 review found an instant increase in airway resistance after using a single e-cigarette.[21] Any reported harmful effects to cardiovascular and respiratory functions after short-term use of e-cigarettes were appreciably milder in comparison to cigarette smoke.[9] When used in the short-term, an e-cigarette resulted in a rise of respiratory resistance comparatively to traditional cigarettes.[60] E-cigarette use could result in respiratory diseases among youth.[131]

There is no data available on the long-term cardiovascular effects.[8] There is no published research available on vaping and thrombosis, platelet reactivity, atherosclerosis, or blood vessel function.[14] 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.[122] Some case reports documented the possible cardiovascular adverse effects from using e-cigarettes, the majority associated was with improper use.[122] 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.[122] E-cigarette use leads to sympathomimetic effects because of nicotine intake.[132] It is argued that there could be a risk for harmful effects, including tachycardia-induced cardiomyopathy.[132] E-cigarettes containing nicotine may have a lower cardiovascular effect than traditional cigarettes containing nicotine.[113] Short-term physiological effects include increases in blood pressure and heart rate.[14] A 2012 case report found a correlation between paroxysmal atrial fibrillation and vaping.[14]

Comparable to a traditional cigarette, e-cigarette particles are tiny enough to enter the alveoli, enabling nicotine absorption.[1] These particles are also tiny enough to go deep in the lungs and enter into the systemic circulation.[5] Local pulmonary toxicity may occur because metal nanoparticles can deposit in the lung's alveolar sacs.[5] E-cigarettes companies assert that the particulates produced by an e-cigarette are too tiny to be deposited in the alveoli.[53] Different devices generate different particle sizes and cause different depositions in the respiratory tract, even from the same nicotine liquid.[115] The aerosol production of e-cigarettes during vaping decreases, which requires a more forceful suction to create a similar volume of aerosol.[66] A more forceful suction could affect the deposition of substances into the lungs.[66] Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern.[133]

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.[87] There were reports of e-cigarettes causing an immune system reaction involving inflammation of the gastrointestinal system.[41] Long-term use could increase the risk of tuberculosis.[12] It is possible that e-cigarettes could harm the periodontium because of the effects of nicotine on gum tissues and the immune system.[134] 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.[87]

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.[19] The user inhales the aerosol, commonly called vapor, rather than cigarette smoke.[24] 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.[24] The aerosol is made-up of liquid sub-micron particles of condensed vapor,[135] which mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and other chemicals.[9] After a puff, inhalation of the aerosol travels from the device into the mouth and lungs.[24] 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.[5]

Various bottles of e-liquid.

After the aerosol is inhaled, it is exhaled.[24] Emissions from electronic cigarettes are not comparable to environmental pollution or cigarette smoke as their nature and chemical composition are completely different[9] The particles are larger, with the mean size being 600 nm in inhaled aerosol and 300 nm in exhaled vapor.[21] Bystanders are exposed to these particles from exhaled e-cigarette vapor.[5] 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.[34][129] Since e-cigarettes involve an aerosolization process, it is suggested that no meaningful amounts of carbon monoxide are emitted.[123] Thus, cardiocirculatory effects caused by carbon monoxide are not likely.[123] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[35] E-cigarettes pose many safety concerns to children.[35] 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.[35]

E-liquid is the mixture used in vapor products such as electronic cigarettes.[52] The main ingredients in the e-liquid usually are propylene glycol, glycerin, nicotine, and flavorings.[101] However, there are e-liquids sold without propylene glycol, nicotine, or flavors.[17][52][61] The liquid typically contains 95% propylene glycol and glycerin.[84] The flavorings may be natural or artificial.[21] About 8,000 flavors exist as of 2014.[136] There are many e-liquids manufacturers in the USA and worldwide.[137] 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.[138] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).[139]

Concerns exists regarding pregnant women exposure to e-cigarette vapor through direct use or via exhaled vapor.[5] No evidence have shown that e-cigarettes are safe to use for pregnant women.[140] No amount of nicotine is safe for pregnant women.[140] 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.[8] E-cigarette are assumed to be dangerous to the fetus during pregnancy if e-cigarettes are used by the mother.[141] Nicotine is harmful to the growing fetus.[142] Nicotine accumulates in the fetus because it goes through the placenta.[38]

As of 2015[update], the long-term issues of e-cigarettes on both mother and unborn baby are unknown.[143] 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.[140] Prenatal nicotine exposure is associated with lower birth weights than other babies,[140]stillbirth,[82]sudden infant death syndrome, and alterations to normal brain development.[140] Prenatal nicotine exposure is associated with asthma and wheezing which may continue into adulthood.[140]Gestational age nicotine exposure is associated with many neurological deficits.[140] Prenatal exposure has been associated with obesity, diabetes, high cholesterol and high blood pressure in minors.[107] Prenatal nicotine exposure in females may lead toward early menarche.[140] An infant was born with necrotizing enterocolitis due to e-cigarette use during pregnancy.[41]

In what way the e-liquid ingredients could affect a fetus is unknown.[2] 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.[109] There are concerns about the health impacts of pediatric exposure to second-hand and third-hand e-cigarette vapor.[18] 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."[17] The belief that e-cigarettes are safer than traditional cigarettes could increase their use in pregnant women.[1] The toxic effects identified with e-cigarette refill liquids on stem cells may be interpreted as embryonic death or birth defects.[1] 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.[35] There is concern for breastfeeding women using e-cigarettes, due to the lack of data on propylene glycol transferring to breastmilk.[21]

There is limited information available on any environmental issues connected to the production, usage, and disposal of e-cigarette models that use cartridges.[37] 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.[37] 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.[37] It is not clear which manufacturing methods are used to make the nicotine used in e-cigarettes.[37] The emissions from making nicotine could be considerable from manufacturing if not appropriately controlled.[37] Some e-cigarette brands that use cartridges state their products are ‘eco-friendly’ or ‘green’, despite the absence of any supporting studies.[37] Some writers contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors.[37]

It is unclear how many traditional cigarettes are comparable to using one e-cigarette that uses a cartridge for the average user.[37] Information is limited on energy and materials used for production of e-cigarettes versus traditional cigarettes, for comparable use.[37] E-cigarettes can be made manually put together in small factories, or they can be made in automated lines on a much bigger scale.[37] Larger plants will produce greater emissions to the surrounding environment, and thus will have a greater environmental impact.[37] 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.[37] A 2014 review found "disposable e-cigarettes might cause an electrical waste problem."[123] Since the majority of e-cigarettes are reusable they are possibly more environmentally friendly than using single-use devices.[144] Compared to traditional cigarettes, e-cigarettes do not create litter in the form of discarded cigarette butts.[144] Traditional cigarette tend to end up in the ocean where they cause pollution.[144]

Marketing and advertisement affects the public’s perception of e-cigarettes.[109] Some tobacco users think vaping is safer than tobacco or other smoking cessation aids.[145] It is generally considered by users that e-cigarettes are safer than tobacco.[114] Many users think that e-cigarettes are healthier than traditional cigarettes for personal use or for other people.[58] Usually, only a small proportion of users are concerned about the possible adverse health effects or toxicity of e-cigarettes.[58] 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.[146] A 2013 four-country survey found higher than 75% of current and former smokers think e-cigarettes are safer than traditional cigarettes.[1] 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".[147] 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."[147] 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."[147]

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.[148] 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?][149]

  1. ^ 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. 
  2. ^ 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. 
  3. ^ 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. 
  4. ^ 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. 
  5. ^ 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. 
  6. ^ 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. 
  7. ^ a b c "Electronic nicotine delivery systems" (PDF). WHO. pp. 1–13. Retrieved 28 August 2014. 
  8. ^ 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. 
  9. ^ 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. 
  10. ^ 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. 
  11. ^ 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. 
  12. ^ 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. 
  13. ^ 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. 
  14. ^ 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. 
  15. ^ 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)
  16. ^ 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. 
  17. ^ 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. 
  18. ^ 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. 
  19. ^ 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. 
  20. ^ 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. 
  21. ^ 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. 
  22. ^ 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. 
  23. ^ a b c Wilder 2016, p. 82.
  24. ^ 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. 
  25. ^ 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. 
  26. ^ a b c d McNeill 2015, p. 77.
  27. ^ a b McNeill 2015, p. 77-78.
  28. ^ 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)
  29. ^ 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. 
  30. ^ 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. 
  31. ^ 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. 
  32. ^ 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. 
  33. ^ 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. 
  34. ^ 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. 
  35. ^ 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. 
  36. ^ 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. 
  37. ^ 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. 
  38. ^ a b c d e f "Electronic Cigarettes – An Overview" (PDF). German Cancer Research Center. 2013. 
  39. ^ 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. 
  40. ^ 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. 
  41. ^ 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. 
  42. ^ "E-Cigarettes". Tobacco Control Research Branch of the National Cancer Institute. 
  43. ^ "Stop smoking treatments". UK National Health Service. 25 July 2014. 
  44. ^ "Standards of Medical Care in Diabetes--2015: Summary of Revisions". Diabetes Care. 54 (38): S25. 2015. doi:10.2337/dc15-S003. PMID 25537706. 
  45. ^ &NA; (August 2014). "E-Cigarettes". Oncology Times. 36 (15): 49–50. doi:10.1097/01.COT.0000453432.31465.77. 
  46. ^ "Nicotine addiction". Health Canada. 7 March 2013. 
  47. ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016. 
  48. ^ Detailed reference list is located at a separate image page.
  49. ^ McNeill 2015, p. 76.
  50. ^ 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. 
  51. ^ "RCP statement on e-cigarettes". Royal College of Physicians. 25 June 2014. 
  52. ^ 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. 
  53. ^ 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. 
  54. ^ "What about electronic cigarettes? Aren’t they safe?". American Cancer Society. 
  55. ^ "Ways to quit". Canadian Cancer Society. 2016. 
  56. ^ "Nicotine products can help people to cut down before quitting smoking". National Institute for Health and Care Excellence. June 2013. 
  57. ^ "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original (PDF) on 6 November 2014. 
  58. ^ 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. 
  59. ^ Detailed reference list is located at a separate image page.
  60. ^ 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. 
  61. ^ 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. 
  62. ^ 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)
  63. ^ 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. 
  64. ^ 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. 
  65. ^ 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. 
  66. ^ 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. 
  67. ^ 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. 
  68. ^ Detailed reference list is located at a separate image page.
  69. ^ 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. 
  70. ^ 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. 
  71. ^ 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. 
  72. ^ a b McNeill 2015, p. 63.
  73. ^ 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)
  74. ^ 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. 
  75. ^ 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. 
  76. ^ 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. 
  77. ^ "Poison Center Calls Involving E-Cigarettes". CDC. 14 April 2016. 
  78. ^ "Electronic Cigarettes and Liquid Nicotine Data" (PDF). American Association of Poison Control Centers. Retrieved 9 January 2016. 
  79. ^ 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. 
  80. ^ 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. 
  81. ^ 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. 
  82. ^ 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. 
  83. ^ 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. 
  84. ^ 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. 
  85. ^ 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. 
  86. ^ 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. 
  87. ^ 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. 
  88. ^ 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. 
  89. ^ "E-Cigarette Poisonings Among Toddlers Skyrocketed 1500% Over 3 Years". Yahoo! News. 9 May 2016. 
  90. ^ a b McNeill 2015, p. 67–68.
  91. ^ "Electronic cigarettes". Therapeutic Goods Administration. 
  92. ^ 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. 
  93. ^ 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. 
  94. ^ a b c d Bart Jansen (23 January 2015). "Packing e-Cigarettes in luggage is a fire risk, FAA warns". USA Today. 
  95. ^ McNeill 2015, p. 43-46.
  96. ^ McNeill 2015, p. 83-84.
  97. ^ a b Ashley Hasley III (26 January 2015). "The FAA wants you to carry on your e-Cigs". The Washington Post. 
  98. ^ 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. 
  99. ^ a b "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). Cancer Research UK. May 2014. 
  100. ^ 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. 
  101. ^ 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. 
  102. ^ Wilder 2016, p. 87.
  103. ^ "E-cigarettes to be regulated as medicines". National Health Service. 12 June 2013. Retrieved 1 August 2013. 
  104. ^ "WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems". World Medical Association. 
  105. ^ 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. 
  106. ^ 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. 
  107. ^ a b c d e "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. 
  108. ^ 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. 
  109. ^ 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. 
  110. ^ 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)
  111. ^ 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. 
  112. ^ 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. 
  113. ^ 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. 
  114. ^ 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. 
  115. ^ 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. 
  116. ^ 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. 
  117. ^ Detailed reference list is located at a separate image page.
  118. ^ 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. 
  119. ^ 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. 
  120. ^ 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. 
  121. ^ 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. 
  122. ^ a b c d e Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (01): 060–065. doi:10.1055/s-0033-1363468. ISSN 0094-6176. PMID 24343348. 
  123. ^ a b c d Nowak D, Jörres RA, Rüther T (2014). "E-cigarettes--prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. doi:10.3238/arztebl.2014.0349. PMC 4047602 . PMID 24882626. CS1 maint: Uses authors parameter (link)
  124. ^ Schroeder, M. J.; Hoffman, A. C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. doi:10.1136/tobaccocontrol-2013-051469. ISSN 0964-4563. PMC 3995273 . PMID 24732160. 
  125. ^ FDA (4 May 2009). "FDA 2009 Study Data: Evaluation of e-cigarettes" (PDF). Food and Drug Administration (US) -center for drug evaluation and research. Retrieved 4 May 2009. 
  126. ^ Golub, Justin S.; Samy, Ravi N. (2015). "Preventing or reducing smoking-related complications in otologic and neurotologic surgery". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (5): 334–340. doi:10.1097/MOO.0000000000000184. ISSN 1068-9508. PMID 26339963. 
  127. ^ Morris, Pamela B.; Ference, Brian A.; Jahangir, Eiman; Feldman, Dmitriy N.; Ryan, John J.; Bahrami, Hossein; El-Chami, Mikhael F.; Bhakta, Shyam; Winchester, David E.; Al-Mallah, Mouaz H.; Sanchez Shields, Monica; Deedwania, Prakash; Mehta, Laxmi S.; Phan, Binh An P.; Benowitz, Neal L. (2015). "Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes". Journal of the American College of Cardiology. 66 (12): 1378–1391. doi:10.1016/j.jacc.2015.07.037. ISSN 0735-1097. PMID 26383726. 
  128. ^ "People who want to quit smoking should consult their GP". Faculty of Public Health. 
  129. ^ a b Kleinstreuer, Clement; Feng, Yu (2013). "Lung Deposition Analyses of Inhaled Toxic Aerosols in Conventional and Less Harmful Cigarette Smoke: A Review". International Journal of Environmental Research and Public Health. 10 (9): 4454–4485. doi:10.3390/ijerph10094454. ISSN 1660-4601. PMC 3799535 . PMID 24065038. 
  130. ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013. p. 8. 
  131. ^ "Position Statement Electronic Cigarettes". Cancer Council Australia, Heart Foundation of Australia. 
  132. ^ a b Nelluri, Bhargava; Murphy, Katie; Mookadam, Farouk; Mookadam, Martina (2016). "The current literature regarding the cardiovascular effects of electronic cigarettes". Future Cardiology. 12 (2): 167–179. doi:10.2217/fca.15.83. ISSN 1479-6678. PMID 26916427. 
  133. ^ "White Paper: Electronic Cigarettes in the Indoor Environment" (PDF). American Industrial Hygiene Association. 19 October 2014. 
  134. ^ Chaffee, Benjamin W.; Couch, Elizabeth T.; Ryder, Mark I. (2016). "The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management". Periodontology 2000. 71 (1): 52–64. doi:10.1111/prd.12120. ISSN 0906-6713. PMC 4842013 . PMID 27045430. 
  135. ^ Offermann, Francis (June 2014). "The Hazards of E-Cigarettes" (PDF). ASHRAE Journal. 56 (6). 
  136. ^ "Backgrounder on WHO report on regulation of e-cigarettes and similar products". 26 August 2014. Retrieved 2 June 2015. 
  137. ^ John Reid Blackwell. "Avail Vapor offers glimpse into the 'art and science' of e-liquids". Richmond Times-Dispatch. Retrieved 2015-11-23. 
  138. ^ Products, Center for Tobacco. "Products, Guidance & Regulations - Deeming – Extending Authorities to Additional Tobacco Products". www.fda.gov. Archived from the original on 2014-04-26. Retrieved 2015-11-23. 
  139. ^ E-Liquid Manufacturing Standards (PDF). US: AMERICAN E-LIQUID MANUFACTURING STANDARDS ASSOCIATION (AEMSA). 2015. pp. 1–13. 
  140. ^ a b c d e f g h Holbrook, Bradley D. (2016). "The effects of nicotine on human fetal development". Birth Defects Research Part C: Embryo Today: Reviews. 108 (2): 181–192. doi:10.1002/bdrc.21128. ISSN 1542-975X. PMID 27297020. 
  141. ^ "Electronic Nicotine Delivery Systems (ENDS), including E-cigarettes". New Zealand Ministry of Health. 
  142. ^ Kaur, J.; Rinkoo, A. V. (2014). "A call for an urgent ban on E-cigarettes in India--a race against time". Global Health Promotion. 22 (2): 71–74. doi:10.1177/1757975914537322. ISSN 1757-9759. PMID 24938513. 
  143. ^ Suter, Melissa A.; Mastrobattista, Joan; Sachs, Maike; Aagaard, Kjersti (2015). "Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (3): 186–195. doi:10.1002/bdra.23333. ISSN 1542-0752. PMC 4830434 . PMID 25366492. 
  144. ^ a b c Brian Clark Howard (11 April 2012). "Cigarettes vs. e-Cigarettes: Which Is Less Environmentally Harmful?". National Geographic. 
  145. ^ Carroll Chapman, SL; Wu, LT (18 Mar 2014). "E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.". Journal of Psychiatric Research. 54: 43–54. doi:10.1016/j.jpsychires.2014.03.005. PMC 4055566 . PMID 24680203. 
  146. ^ Tomashefski, Amy (2016). "The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review". Journal of the American Association of Nurse Practitioners: n/a–n/a. doi:10.1002/2327-6924.12358. ISSN 2327-6886. PMID 26997487. 
  147. ^ a b c "Electronic cigarette use among smokers slows as perceptions of harm increase". ASH. 22 May 2015. Retrieved 6 August 2015. 
  148. ^ McNeill 2015, p. 79.
  149. ^ McNeill 2015, p. 6, 11, 79-80.

 

Uk E Liquid Free Delivery UK

Uk Vape Companies UK

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.

Electronic Smoking Cigarette

UK Electronic Cigarettes and E-Liquid

[Thorpe] Welcometo Beyond the Data.

I'm Dr.

Phoebe Thorpe, and herewith me today is Dr.

Brian King from CDC's Office onSmoking and Health.

Thank you for joining us Brian.

[King] Thanks somuch for having me.

It's a pleasure to be here.

[Thorpe] Our topictoday is E-cigarettes.

Can you tell us why they areconsidered a tobacco product? [King] Yes, so in the UnitedStates we regulate tobacco products through the US Foodand Drug Administration, and the way they describe atobacco product is any product that's made or derivedfrom tobacco.

And we know that the vastmajority of nicotine that's used in tobacco products,including e-cigarettes, is indeed derived from tobacco.

So since these productscontain nicotine, we consider them a tobaccoproduct in the United States.

[Thorpe] And E-cigarettesare little bit different than regular cigarettes.

Can you describe how they work? [King] Yeah, so E-cigarettes isshort for electronic cigarettes, but we know them by alot of different names.

And they can be calledthings like vapor products, hookah pens, vape pens, butthe bottom line is they're all really the same product.

And they work by containinga liquid that's heated which the user then inhales intotheir lungs, and it's important to note that this isn'ttechnically a vapor which is how peoplefrequently refer to.

It's actually an aerosol thatcontains small particles as well as various other ingredientsthat the user inhales, and so there's no combustion.

You're not burning anything, butthere is a heating of the liquid which turns into an aerosolwhich the user inhales.

And they can alsoexhale into the air as other bystandersare around them.

[Thorpe] And the aerosolis not just water vapor.

I mean, that's animportant part to understand because I get asked as aphysician about E-cigarettes, and the thing from the session that I found veryinteresting was the idea that were not reallycertain about the risks that flavorings addto E-cigarettes.

The one that was mentioned wasthe butter flavoring Diacetyl that has been associatedwith bronchiolitis obliterans or what's called popcorn lung,which is a deadly disease.

What more do we know aboutthe risks of E-cigarettes? [King] So our knowledgeabout what's contained in both the E-cigaretteliquid as well as the aerosol hascontinued to evolve over time that these products enteredthe United States marketplace in around 2007.

They didn't really start touptick in use until 2010, 2011.

But, since that time, we reallyincreased the amount of research into what these productscontain.

And what we can say isthat the aerosol admitted by these productsis not harmless.

We do know that the ingredients and the levels aresignificantly less dangerous than conventional cigarettes,but that doesn't mean that they're completelyrisk-free.

And so, some of theingredients we found in the E-cigaretteaerosol are things like ultrafine particulatethat can be inhaled very deep into the lungs, and alsoheavy metals that are found in the filaments of the deviceand are omitted in the aerosol, as well as, things likevolatile organic compounds.

But one of the most commoningredients is nicotine, and we know that nicotineis highly addictive.

But there's alsoevidence indicating that it can harm thedeveloping adolescent brain which really makes itimportant for youth to avoid these devices.

In addition to some of theseother harmful ingredients, we also know the flavorings.

And so, Diacetyl is justone, but there are a variety of different flavoringsthat are used that, although they may be safe toingest in things like food, we don't know what the risks are for inhaling thesedevices into the lungs.

You know, your gut can handlea lot more than your lungs, and that's reallyimportant when we look at the ingredientsin these products.

And finally, it's alsoimportant to remember that people are using a lotof things in E-cigarettes, and that includes otherpsychoactive substances like marijuana andTHC and others.

And so, when we are talkingabout youth in particular, the use of both the nicotinecontaining varieties as well as other varietiesfor other types of drugs are really apublic health concern.

[Thorpe] Okay.

But we have had somerecent good news about the youth meaningmiddle school and high school useof E-cigarettes.

Can you tell me about that? [King] Yes.

It's really a commendablepublic health accomplishment.

We started assessing E-cigaretteuse among youth in this country in 2011, and through 2015,we saw exponential increases in the use of this product.

And 2016 was the first time that we actually saw declineamong youth in this country, and that was really a resultof the coordinated efforts to not only educate thepublic about the harms of youth E-cigarette use but also implementingcommon sense strategies to not only prevent youth accessbut also to protect people from the aerosol andpublic environments and various other campaigns to educate peopleabout these products.

But, on balance, the badnews is that we still have over 2 million youth thatare using E-cigarettes, and they're now the mostcommonly used tobacco products used among US youth.

So we made great progress,but we really need to continue that momentum toreduce all forms of tobacco productuse among youth.

[Thorpe] So it's going down, butnot as lot much as we'd like.

So what's driving the use ofthe E-cigarettes in teens? [King] So there's avariety of factors that we believe are contributingto these increased rates of use among youth thatwe saw through 2015.

One of the most notable is theadvertising for these products.

We know that many of the themesand tactics that have been used to advertise conventionalcigarettes are frequently used for E-cigarettes.

And we also know thatthere's some media of for which conventional cigaretteadvertising is banned that is allowed forE-cigarettes.

Things like television.

And so, there's reallya prominent advertising of these products, and we know that it's reachingkids in particular.

About 18 million US youthreported being exposed to E-cigarette ads in 2014.

Another factor isflavorings, and we know, from the existing science, that flavorings can beparticularly appealing in terms of enticing youth and youngadults to use tobacco products.

And a variety of E-cigarettesare flavored, and we know, from the existing data, thatabout two thirds of youth who use these cigarettes reportusing flavored varieties, and flavors are the mostcommonly cited reason for why youth startedusing these products.

And so, in the end, wereally have a situation where you know the advertisingis bringing the horse to water.

The flavorings aregetting them to drink, and then the nicotine is keepingthem coming back for more.

And so, it's kind of aperfect storm in terms of the youth rates of this use.

But the good news is, we knowwhat works to prevent that.

And if we implement those commonsense public health strategies, we can continue to seethe declines that we saw within the past yearamong our nation's youth.

[Thorpe] And the realconcern is about nicotine and the teenage brain.

Can you just briefly tell mea little bit more about that? [King] Yeah.

So nicotine is found in thevast majority of E-cigarettes that are sold on the U.

S.

marketand, you know, nicotine we use in things like nicotinereplacement therapy among adults.

And it can be, youknow, an effective drug to help people quitconventional cigarette smoking.

But it's important to note thatthose are in very measured doses and weans the individual off of conventional cigarettesover time.

But nicotine is notnecessarily risk-free.

Particularly forvulnerable populations.

We know that nicotineis highly addictive, but there's also a growingbody of scientific evidence that was outlined in a recentSurgeon General's Report noting that nicotine exposure can harmthe developing adolescent brain.

And we know that thebrain continues to develop into young adulthood upthrough 25 or 26, and so, there's really implicationsfor not only youth use of these products butalso young adult use of any nicotine containingproduct.

And another thing to remember with nicotine is it'salso been shown to result in adverse health outcomesamong pregnant women in particularly fetal toxicity.

So there's also implications about pregnant womenusing any form of nicotine containing product,and so, it's really important for them to talk with theirphysician before they use any type of nicotine containingproduct including E-cigarettes.

[Thorpe] So is there a placethat physicians could go to learn a little bitmore about these parts with the E-cigarettesand the nicotine? [King] So there's many resourcesthat have been developed over the past fewyears, particularly as the sciences begun to grow.

And we have, you know,more concrete evidence about what works effectivelyto help warn people about these products and alsoprovide them scientific-based information to makeinformed decisions.

And in 2016, the U.

S.

SurgeonGeneral released a landmark report on E-cigarette useamong youth and young adults.

And as part of therelease of that report, there were severalmaterials including resources and provider cards to helphealth professionals really communicate to both childrenand adults about these products.

And so, in the context of youth, it really enforces theimportance of warning them about the dangersof these products.

Particularly with regardto the nicotine content.

And among adults, it's amore nuanced conversation about knowing that we dohave FDA approved medications to help people quit, and thoseshould really be the first line of defense to help you quit.

And if that doesn't work, youcan consider E-cigarettes, but in consultation withyour healthcare provider.

And right now, based onthe evidence we have, there is no conclusive evidencethat E-cigarettes are effective for long-term cessation, andso, it's really important to use those resources thatwe know are most effective to help you quitand in coordination with your healthcare provider.

[Thorpe] And then foryouth, where if parents or other adults wanted to knowmore about how they could talk to teens and young adults aboutthe risks of E-cigarettes, where would they find someinformation about that? [King] So as part of the releaseof the Surgeon General's Report, there's an excellent interactivewebsite that was coordinated with the release of that report, and it isE-cigarettes.

Surgeongeneral.

Gov.

And it has a varietyof information on both the reportitself as well as a public service announcementas well as informational cards for both parents andclinicians to educate our youth and young adults in particularabout the dangers and risks of using these products.

[Thorpe] That sounds like anexcellent place for our viewers to go and see whatthey can find out.

Thank you very muchfor joining us.

[King] Thank you verymuch for having me.

[Thorpe] And thankyou for joining us.

See you next monthon Beyond the Data.

Highest Rated Electronic Cigarette

Electronic cigarette

 UK

The entering into force of the requirements of the European tobacco products directive in Estonia made e-cigarette seller Nicorex Baltic destroy 19,000 bottles of e-cigarette liquid worth €135 000, as the packaging size did not meet the new requirements.

The liquids were actually in order, had undergone laboratory testing and met the new requirements, but their packaging did not have the necessary warnings on them and the boxes did not contain instructions.

Nicorex said that the transition period allowed by the government was too short, as the shelf life of the liquids was two years, but the length of the transition period only one year.

At the same time, Nicorex welcomed the requirement that the liquids have to undergo laboratory testing and that both the equipment and liquids must be registered in a single European database.

Nicorex described the restrictions concerning the size of packaging as unreasonable, as they increased the ecological footprint.

The transition period under the new tobacco law arising from the European tobacco products directive will end on May 20, after which the stricter requirements will apply to e-cigarettes in full.

Liquids can't be sold in containers bigger than 10 ml, they can't contain more nicotine than 20 milligrams per milliliter, and the vaporizer can't be bigger than 2 ml.

The packaging needs to include a leaflet, instructions, a batch number, a date, and a warning that nicotine is an addictive substance.


 

Uk E Liquid Free Delivery UK

Uk Manufactured E Liquid UK

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.

Highest Rated Electronic Cigarette

UK Electronic Cigarettes and E-Liquid

Various types of e-cigarettes.

Electronic cigarettes or e-cigarettes[note 1] are handheld electronic devices that try to create a feeling like smoking tobacco. They work by heating a liquid to generate an aerosol, commonly called a "vapor", that the user inhales.[2] Using e-cigarettes is sometimes called vaping.[4] The liquid in the e-cigarette, called e-liquid,[5] is usually made of nicotine, propylene glycol, glycerine, and flavorings.[6] Not all e-liquids contain nicotine.[7]

The health risks of e-cigarettes are uncertain.[8][9][10] They are likely safer than tobacco cigarettes,[11][12] but the long-term health effects are not known.[13][14][15][16][17] They can help some smokers quit.[6][18] When used by non-smokers, e-cigarettes can lead to nicotine addiction, and there is concern that children could start smoking after using e-cigarettes.[19] According to some US sources, minors who use e-cigarettes are more likely to smoke later in life.[20][21] Public Health England attributes this link to a liability for the use of both products rather than one resulting in the other.[15][22] So far, no serious adverse effects have been reported in trials.[6] Less serious adverse effects include throat and mouth irritation, vomiting, nausea, and coughing.[23]

E-cigarettes create an aerosol, commonly called vapor,[23][24] generally containing nicotine, flavors, glycerol and propylene glycol.[25] Its exact composition varies.[24] The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette aerosol.[26][27] Those present are mostly below 1% corresponding levels in tobacco smoke.[28][29] The aerosol can contain toxicants and traces of heavy metals at levels permissible in inhalation medicines,[25] and potentially harmful chemicals not found in tobacco smoke at concentrations permissible by workplace safety standards.[28] However, chemical concentrations may exceed the stricter public safety limits.[23]

The modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik,[30] and as of 2015 most e-cigarettes are made in China.[31] Since they were first sold in 2004 their global use has risen exponentially.[32] In the United States and the United Kingdom their use is widespread, and some US schoolchildren use them.[33] Reasons for using e-cigarettes involve trying to quit smoking, reduce risk, or save money, though many use them recreationally.[13] A majority of users still smoke tobacco, causing concerns that dual use may "delay or deter quitting".[23] About 60% of UK users are smokers and roughly 40% are ex-smokers, while use among never-smokers is "negligible".[34] Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is debated in many countries.[35] A European directive in 2016, set limits for liquids and vaporizers, ingredients, and child-proof liquid containers.[36] As of August 2016, the US FDA extended its regulatory power to include e-cigarettes.[37] There are around 500 brands of e-cigarette with global sales in excess of US$7 billion.[38]

Electronic cigarettes are also known as e-cigarettes, e-cigs, EC,[1] electronic nicotine delivery systems (ENDS) or electronic non-nicotine delivery systems (ENNDS),[2] personal vaporizers, or PVs.[3] They are handheld devices, often made to look like conventional cigarettes, and used in a similar way.[2][39] E-liquid[5] or juice are names for the flavored solution that goes inside the e-cigarette.[40] An aerosol, or vapor, is produced by heating the e-liquid.[41] Irish public health discussions refer to NMNDS ("non-medicinal nicotine delivery systems").[42]

Aerosol (vapor) exhaled by an e-cigarette user.

Since their introduction to the market in 2004, global usage of e-cigarettes has risen exponentially.[32] By 2013, there were several million users globally.[43] Awareness and use of e-cigarettes greatly increased in a relatively short period of time.[44] However, growth in the US and UK had reportedly slowed in 2015, lowering market forecasts for 2016.[45][46]

Most users have a history of smoking regular cigarettes.[47] At least 52% of smokers or ex-smokers have vaped.[31] Of smokers who have, less than 15% became everyday e-cigarette users.[6] Though e-cigarette use among those who have never smoked is very low, it continues to rise.[48] A survey of e-cigarette users conducted from 2011–2012 found that only 1% of respondents used liquid without nicotine.[49]

Everyday use is common among e-cigarette users.[50] Vapers mostly keep smoking,[23] although many say vaping helps them cut down or quit smoking.[25][47] Most e-cigarette users are middle-aged men who also smoke traditional cigarettes, either to help them quit or for recreational use.[13] E-cigarette use was also rising among women as of 2014.[51] Some young people who have tried an e-cigarette have never smoked tobacco, so ECs can be a starting point for nicotine use.[23] On the other hand, Public Health England found no evidence e-cigarettes increase teen tobacco smoking. They noted tentative evidence that e-cigarettes divert youth away from cigarettes.[12] A 2014 review raised ethical concerns about minors' e-cigarette use and the potential to weaken cigarette smoking reduction efforts.[52]

In the US, as of 2014, 12.6% of adults had used an e-cigarette at least once and approximately 3.7% were still using them.[53] 1.1% of adults were daily users.[54] Non-smokers and former smokers who had quit more than four years earlier were extremely unlikely to be current users.[54] Former smokers who had recently quit were more than four times as likely to be daily users as current smokers.[54] Experimentation was more common among younger adults, but daily users were more likely to be older adults.[54]

Play media National Institute on Drug Abuse director Nora Volkow discussing a study that shows teens using e-cigarettes are more likely to start smoking tobacco.[55]

The recent decline in smoking has accompanied a rapid growth in the use of alternative nicotine products among young people and young adults.[56] In the US, vaping among young people exceeded smoking in 2014.[57] As of 2014, up to 13% of American high school students have used them.[33] Between 2013 and 2014, vaping among students tripled.[58] In 2013 the Centers for Disease Control and Prevention (CDC) estimated that around 160,000 students between 2011 and 2012 who had tried vaping had never smoked.[56] E-cigarette use among never-smoking youth in the US correlates with elevated desires to use traditional cigarettes.[8] Teenagers who had used an e-cigarette were more inclined to become smokers than those who had not.[59] In the 2015 Monitoring the Future survey, a majority of students who used electronic cigarettes reported using liquid without nicotine the last time they vaped.[60] The majority of young people who vape also smoke.[61] A 2010–2011 survey of students at two US high schools found that vapers were more likely to use hookah and blunts than smokers.[62] Among grade 6 to 12 students in the US, the proportion who have tried them rose from 3.3% in 2011 to 6.8% in 2012.[47] Those still vaping over the last month rose from 1.1% to 2.1% and dual use rose from 0.8% to 1.6%.[47] Over the same period, the proportion of grade-6-to-12 students who regularly smoke tobacco fell from 7.5% to 6.7%.[63]

In the UK, user numbers have increased from 700,000 in 2012 to 2.6 million in 2015, but use by current smokers remained flat at 17.6% from 2014 into 2015 (in 2010, it was 2.7%).[34] About one in 20 adults in the UK uses e-cigarettes.[64] In the UK in 2015, 18% of regular smokers said they used e-cigarettes and 59% said they had used them in the past.[34] Among those who had never smoked, 1.1% said they had tried them and 0.2% still use them.[65] In 2013, among those under 18, 7% have used e-cigarettes at least once.[65] Among non-smokers' children, 1% reported having tried e-cigarettes "once or twice", and there was no evidence of continued use.[65] About 60% of all users are smokers and most of the rest are ex-smokers, with "negligible" numbers of never-smokers.[66] In 2015 figures showed around 2% monthly EC-usage among under-18s, and 0.5% weekly, and despite experimentation, "nearly all those using EC regularly were cigarette smokers".[67] 10–11-year-old Welsh never-smokers are more likely to use e-cigarettes if a parent used e-cigarettes.[68]

In France in 2014, between 7.7 and 9.2 million people have tried e-cigarettes and 1.1 to 1.9 million use them on a daily basis.[69] 67% of French smokers use e-cigarettes to reduce or quit smoking. Of French people who have tried e-cigarettes, 9% have never smoked tobacco.[69] Of the 1.2% who had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited e-cigarettes as essential in quitting.[69]

The frequency of vaping in youth is low.[70] Minors who use one tobacco product such as e-cigarettes are more likely to later use other tobacco products such as cigarettes,[20] which likely arises from a common liability for the use of both products.[15] Young people who vape but do not smoke are more likely to try smoking than their peers who do not vape.[71]

E-cigarettes often have a high-tech look.[72] Candy, fruit and coffee flavored e-liquid.[73]

Reasons for e-cigarette use often relate to quitting smoking and recreation.[13][50][74] Many users believe vaping is healthier than smoking, although some are concerned about possible adverse health effects.[50] Some use them to circumvent smoke-free laws and policies, or to cut back on cigarette smoking.[23] 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking.[9] In the same survey, 26% of respondents would use them in areas where smoking was banned.[9] Not having odor from smoke on clothes on some occasions prompted interest in or use of e-cigarettes.[50] Many e-cigarette users use them because they believe they are safer than conventional cigarettes.[74]

Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one.[62] College students often vape for experimentation.[75] Expensive marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use".[76] Exposure to e-cigarette advertising influenced people to try them.[59]

Some researchers are concerned about vaping during pregnancy.[8][77] E-cigarettes feel or taste similar to traditional cigarettes, and vapers disagreed about whether this was a benefit or a drawback.[50] The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.[50]

Some users stopped vaping due to issues with the devices.[50] Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use.[64] Some surveys found that a small percentage of users' motives were to avoid smoking bans, but other surveys found that over 40% of users said they used the device for this reason.[50]

The health and lifestyle appeal may also encourage young non-smokers to use e-cigarettes, as they may perceive that trying e-cigarettes is less risky and more socially appealing. This may decrease negative beliefs or concerns about nicotine addiction.[73] Marketing might appeal to young people as well as adults.[78] Adolescent experimenting with e-cigarettes may be sensation seeking behavior, and is not likely to be associated with tobacco reduction or quitting smoking.[8] Young people may view e-cigarettes as a symbol of rebellion.[48] The main reasons young people experimented with e-cigarettes were due to curiosity, flavors, and peer influences.[79] The National Association of County and City Health Officials say there is concern that e-cigarettes may appeal to youth because of their high-tech design, assortment of flavors, and accessibility online.[72] The Heart and Stroke Foundation claims that candy and fruit flavored e-cigarettes are designed to appeal to young people.[80] Infants and toddlers could ingest the e-liquid from an e-cigarette device out of curiosity.[81]

Users may begin by trying a disposable e-cigarette.[70] Users often start with e-cigarettes resembling normal cigarettes, eventually moving to a later-generation device.[82] Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit",[82] and users may adjust their devices to provide more vapor for better "throat hits".[83]

Special e-liquid mixes with THC or other cannabinoids are sold.[84]

The emergence of e-cigs has given cannabis smokers a new method of inhaling cannabinoids.[84] E-cigs differ from traditional marijuana cigarettes in several respects.[84] It is assumed that vaporizing cannabinoids at lower temperatures is safer because it produces smaller amounts of toxic substances than the hot combustion of a marijuana cigarette.[84] Recreational cannabis users can discreetly "vape" deodorized cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as "stealth vaping".[84] While cannabis is not readily soluble in the liquid used for e-cigs, recipes containing synthetic cannabinoids which are soluble may be found on the Internet.[84]

E-cigarettes may be used with other substances and cartridges can potentially be filled with e-liquid containing substances other than nicotine, thus serving as a new and potentially dangerous way to deliver other psychoactive drugs,[85] for example THC.[84]

Cannabinoid-enriched e-liquids require lengthy, complex processing. Some are available on the Internet despite lack of quality control, expiry date, conditions of preservation, or any toxicological and clinical assessment.[84] The health consequences of vaping cannabis preparations are largely unknown.[84]

Exploded view of electronic cigarette with transparent clearomizer and changeable dual-coil head. This model allows for a wide range of settings.[86] Electronic cigarettes can come in very different forms—such as this hand-grenade-shaped variant.

The main components of an e-cigarette are a mouthpiece, a cartridge (tank), a heating element/atomizer, a microprocessor, a battery, and possibly a LED light on the end.[87] The only exception to this are mechanical e-cigarettes (mods) which contain no electronics; the circuit is closed by a mechanical action switch.[88] An atomizer comprises a small heating element, or coil, that vaporizes e-liquid and wicking material that draws liquid onto the coil.[89] When the user pushes a button,[75] or (in some variations) activates a pressure sensor by inhaling, the heating element atomizes the liquid solution.[13] The e-liquid reaches a temperature of roughly 100-250 °C within a chamber to create an aerosolized vapor,[90] which the user then inhales, rather than cigarette smoke.[24] The aerosol provides a flavor and feel similar to tobacco smoking.[91]

There are three main types of e-cigarettes: cigalikes, looking like cigarettes; eGos, bigger than cigalikes with refillable liquid tanks; and mods, assembled from basic parts or by altering existing products.[8] As the e-cigarette industry continues to evolve, new products are quickly developed and brought to market.[92] First generation e-cigarettes tend to look like tobacco cigarettes and so are called "cigalikes".[93] Most cigalikes look like cigarettes but there is some variation in size.[94] A traditional cigarette is smooth and light while a cigalike is rigid and slightly heavier.[91] Second generation devices are larger overall and look less like tobacco cigarettes.[95] Third generation devices include mechanical mods and variable voltage devices.[93] The fourth generation includes Sub ohm tanks and temperature control devices.[96] The power source is the biggest component of an e-cigarette,[32] which is frequently a rechargeable lithium-ion battery.[97]

E-liquid is the mixture used in vapor products such as e-cigarettes[98] and generally consists of propylene glycol, glycerin, water, nicotine, and flavorings.[18] While the ingredients vary[6][70][98] the liquid typically contains 95% propylene glycol and glycerin.[99] There are many e-liquids manufacturers in the USA and worldwide,[100] and upwards of 8,000 flavors.[38] While there are currently no US Food and Drug Administration (FDA) manufacturing standards for e-liquid, the FDA has proposed regulations that were expected to be finalized in late 2015.[100][needs update] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).[101]

Main article: Positions of medical organizations on electronic cigarettes 2014 Centers for Disease Control (CDC) press release about e-cigarettes.[102]

Medical organizations differ about the health implications of vaping.[103] Many medical organizations have made statements about their health and safety. There is general agreement that e-cigarettes expose users to fewer toxicants than tobacco.[6][103] International organizations have hesitated to recommend e-cigarettes for quitting smoking, because of limited evidence of effectiveness and safety.[19][44][104] Some from the UK have recommended their use by smokers unwilling or unable to quit.[105][106]

In August 2016, a World Health Organization (WHO) report found "there is not enough research to quantify the relative risk of ENDS/ENNDS over combustible products. Therefore, no specific figure about how much 'safer' the use of these products is compared to smoking can be given any scientific credibility at this time."[107] In July 2014, a WHO report found limited evidence that e-cigarettes may help some smokers quit, but did not reach conclusions.[19] Smokers should be encouraged to use approved methods for help with quitting,[19] although e-cigarettes may have a role in helping those who have failed to quit by other means.[19] Smokers will get the maximum health benefit if they completely quit all nicotine use.[19] A policy briefing by the Framework Convention Alliance notes widespread agreement that e-cigarettes are "almost certainly considerably less hazardous for individuals than cigarettes", but also notes widespread disagreement on the likelihood and impact of dual use, uptake by never-smokers, and re-normalisation of smoking.[103] The World Lung Foundation has applauded the WHO report's recommendation of tighter regulation due to safety concerns and the risk of increased nicotine addiction or tobacco use among young people.[108]

In a 2015 joint statement, Public Health England and twelve other UK medical bodies concluded "e-cigarettes are significantly less harmful than smoking".[29] PHE also stated that e-cigarettes are estimated to be 95% less harmful than smoking.[109] The UK National Health Service believes that e-cigarettes have about 5% of the risk of tobacco cigarettes,[110] but also feels there will not be a complete understanding of their safety for many years.[110] There are clinical trials in progress to test the quality, safety and effectiveness of e-cigarettes, but until these are complete the NHS maintains that the government could not give any advice on them or to recommend their use.[111] In 2016, the Royal College of Physicians called to "promote e-cigarettes widely as substitute for smoking", concluding that "e-cigarettes are likely to be beneficial to UK public health".[15][112]

The United States Centers for Disease Control and Prevention released a 2016 report titled E-cigarette Ads and Youth which concerned marketing towards adolescents.[113]

In 2016, the FDA stated its position that e-cigarettes are "likely less hazardous for an individual user than continued smoking of traditional cigarettes", but that the net population effect is unknown.[16] In 2015, the United States Preventive Services Task Force concluded there is insufficient evidence to recommend e-cigarettes for smoking cessation, and recommended clinicians instead recommend more proven smoking cessation aids.[114] The National Institute on Drug Abuse raises concern over the possibility that they could perpetuate nicotine addiction and thus interfere with quitting.[115] In 2015, the American Academy of Pediatrics strongly recommended against using e-cigarettes to quit smoking, stating that for adolescents e-cigarettes are not effective in treating tobacco dependence.[116] In August 2014, the American Heart Association released a policy statement concluding that while e-cigarette aerosol is much less toxic then cigarette smoke, there is insufficient evidence for clinicians to counsel smokers to use them as a primary cessation aid. If a patient failed initial treatment or refuses to use cessation medication, and wishes to use e-cigarettes to quit, it is reasonable to support the attempt after informing about the uncertainties.[117] In 2014, the US FDA said "E-cigarettes have not been fully studied, so consumers currently don't know: the potential risks of e-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products. Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death."[104]

Play media CDC launches "Tips From Former Smokers" ad campaign in 2015. The main information on e-cigarettes begins at 24:45.[118]

The available research on e-cigarette use for smoking cessation is limited to three randomized controlled trials and some user surveys, case reports, and cohort studies.[119] Some consider the evidence contradictory,[9][117] while others attribute negative outcomes to inappropriate study design.[6][105][120] Some medical authorities recommend that e-cigarettes have a role in smoking cessation, and others disagree. On the one hand, Public Health England recommends that stop-smoking practitioners should (1) advise people who want to quit to try e-cigarettes if they are failing with conventional nicotine replacement therapy (NRT); and (2) advise people who cannot or do not want to quit to switch to e-cigarettes.[29] On the other hand, the United States Preventive Services Task Force advised only use of conventional NRT products in smoking cessation and found insufficient evidence to recommend e-cigarettes for this purpose.[9]

There is tentative evidence that they can help people quit smoking,[6] but studies pertaining to their potential impact on smoking cessation and reduction is very limited.[121] However, a 2016 meta-analysis based on 20 different studies found that smokers who used electronic cigarettes were 28% less likely to quit than those who had not tried electronic cigarettes.[122] This finding persisted whether the smokers were initially interested in quitting or not.[122] A 2015 meta-analysis on clinical trials found that nicotine-containing e-liquids are more effective than nicotine-free ones for quitting smoking. They compared their finding that nicotine-containing e-cigarettes helped 20% of people quit with the results from other studies that found conventional NRT helps 10% of people quit.[123] There has only been one study directly comparing first generation e-cigarettes to conventional NRT as smoking cessation tools, so the comparative effectiveness is not known.[123] Two 2016 reviews found a trend towards benefit of e-cigarettes with nicotine for smoking cessation, but that the evidence was of low quality.[124][125] Another 2016 review found that the combined abstinence rate among smokers using e-cigarettes in prospective studies was 29.1%. The same review noted that few clinical trials had yet been conducted on their effectiveness, and only one had included a group using other cessation methods.[126]

However, e-cigarettes have not been subject to the same efficacy testing as nicotine replacement products. Several authorities, including the World Health Organisation, take the view that there is not enough evidence to recommend e-cigarettes for quitting smoking in adults,[9] and there are studies showing a decline in smoking cessation among dual users.[122] A 2014 review found that e-cigarettes do not seem to improve cessation rates compared to regulated nicotine replacement products, and a trial found 29% of e-cigarette users were still vaping at 6 months, but only 8% of patch users still wore patches at 6 months.[47] There is low-quality evidence that vaping assists smokers to quit smoking in the long-term compared with nicotine-free vaping.[127] Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine.[123] E-cigarettes without nicotine may reduce tobacco cravings because of the smoking-related physical stimuli.[128]

Tobacco harm reduction (THR) is replacing tobacco cigarettes with lower risk products to reduce death and disease.[129] THR has been controversial out of fear that tobacco companies cannot be trusted to make products that will reduce this risk.[128] E-cigarettes can reduce smokers' exposure to carcinogens and other toxic substances found in tobacco.[128][130]

Tobacco smoke contains 100 known carcinogens, and 900 potentially cancer causing chemicals,[98] none of which has been found in more than trace quantities in e-cigarette vapor.[128] While e-cigarettes cannot be considered "safe" because there is no safe level for carcinogens, they are doubtless safer than tobacco cigarettes.[128] E-cigarettes are not dangerous enough to warrant serious public health concerns given the known risks of conventional cigarettes. The same review concluded that evidence supported "the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking", provided efforts were also made to protect vulnerable groups from e-cigarettes.[131]

A core concern is that smokers who could have quit completely will develop an alternative nicotine addiction instead.[128] A 2014 review stated that promotion of vaping as a harm reduction aid is premature,[132] but they could help to lower tobacco-related death and disease if examined more thoroughly.[18] Another review found that compared with cigarettes, e-cigarettes are likely to be much less, if at all, harmful to users or bystanders.[25] The authors warned against the potential harm of excessive regulation and advised health professionals to consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking.[25] A 2015 Public Health England report concluded that e-cigarette use "releases negligible levels of nicotine into ambient air with no identified health risks to bystanders".[133] A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction.[134] A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions.[91] E-cigarette use for risk reduction in high-risk groups such as people with mental disorders is unavailable.[135]

Hazards associated with products currently on the market are probably low, and certainly much lower than smoking. However, harms could be reduced further through appropriate product standards.[26] Many smokers want to reduce harm from smoking by using these products.[26] The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.[136] The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and smokeless tobacco for long term use instead of smoking.[137] In an interview, the director of the Office on Smoking and Health for the U.S. federal agency Centers for Disease Control and Prevention (CDC) believes that there is enough evidence to say that using e-cigarettes is likely less harmful than smoking a pack of conventional cigarettes.[138] However, due to the lack of regulation of the contents of e-cigarettes and the presence of nicotine, the CDC has issued warnings.[138] A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both.[19] This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."[19]

Main articles: Safety of electronic cigarettes and Electronic cigarette aerosol and e-liquid Adverse effects of vaping.[139]

The safety of electronic cigarettes is uncertain.[8][9][10] However, they are likely substantially safer than tobacco cigarettes.[6][117][140] There is considerable variation between vaporizers and in quality of their liquid ingredients and thus the contents of the vapor.[23][141][142] Reviews on the safety of electronic cigarettes, analyzing almost the same studies, resulted in substantially different conclusions.[143] In July 2014 the World Health Organization (WHO) report cautioned about potential risks of using e-cigarettes.[19] Regulated US Food and Drug Administration (FDA) products such as nicotine inhalers are probably safer than e-cigarettes.[132] In 2015, Public Health England stated that e-cigarettes are estimated to be 95% less harmful than smoking.[109] A 2014 systematic review concluded that the risks of e-cigarettes have been exaggerated by health authorities and stated that while there may be some remaining risk, the risk of e-cigarette use is likely small compared to smoking tobacco.[27]

The long-term effects of e-cigarette use are unknown.[75][13][127] Improvements in lung function and pulmonary health have been demonstrated among smokers who have switched to e-cigarettes.[144][145] A 2014 Cochrane review found no serious adverse effects reported in clinical trials.[6] Less serious adverse effects from e-cigarette use include throat and mouth irritation, vomiting, nausea, and cough.[23] The evidence suggests they produce less harmful effects than tobacco.[146] A 2014 WHO report said, "ENDS use poses serious threats to adolescents and fetuses."[19] Aside from toxicity, there are also risks from misuse or accidents[27] such as contact with liquid nicotine,[147] fires caused by vaporizer malfunction,[23] and explosions as result from extended charging, unsuitable chargers, or design flaws.[27] Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns.[8] There is a small risk of battery explosion in devices modified to increase battery power.[90]

The e-liquid has a low level of toxicity, but contamination with various chemicals has been found.[148] The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor.[26][27] Those which are present are mostly below 1% of the corresponding levels in tobacco smoke, and far below safety limits for occupational exposure.[28][149] Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals.[27] Normal usage of e-cigarettes generates very low levels of formaldehyde.[150] A 2015 review found that later-generation e-cigarettes set at higher power may generate equal or higher levels of formaldehyde compared to smoking.[75][151] A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage.[150] The 2015 Public Health England report looking at the research concluded that by applying maximum power and increasing the time the device is used on a puffing machine, e-liquids can thermally degrade and produce high levels of formaldehyde.[12] Users detect the "dry puff" and avoid it, and the report concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes."[12] E-cigarette users who use e-cigarettes that contain nicotine are exposed to its potentially harmful effects.[24] Nicotine is associated with cardiovascular disease, potential birth defects, and poisoning.[152]In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo.[152] There is inadequate research to demonstrate that nicotine is associated with cancer in humans.[153] The risk is probably low from the inhalation of propylene glycol and glycerin.[25] No information is available on the long-term effects of the inhalation of flavors.[148] Most of the cardiovascular effects of ECs are consistent with those of nicotine. According to a 2017 review, it is possible that ECs may have adverse cardiovascular effects on users, especially those who already have cardiovascular disease. However, this review also concluded that "the risk is thought to be less than that of cigarette smoking based on qualitative and quantitative comparisons of EC aerosol versus cigarette smoke constituents."[154]

E-cigarettes create vapor that consists of ultrafine particles, with the majority of particles in the ultrafine range.[23] The vapor has been found to contain flavors, propylene glycol, glycerin, nicotine, tiny amounts of toxicants, carcinogens, heavy metals, and metal nanoparticles, and other chemicals.[23][25] Exactly what comprises the vapor varies in composition and concentration across and within manufacturers.[24] However, e-cigarettes cannot be regarded as simply harmless.[155] There is a concern that some of the mainstream vapor exhaled by e-cigarette users can be inhaled by bystanders, particularly indoors.[32] E-cigarette use by a parent might lead to inadvertent health risks to offspring.[77] A 2014 review recommended that e-cigarettes should be regulated for consumer safety.[134] There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges.[156] A 2014 review found "disposable e-cigarettes might cause an electrical waste problem."[135]

The World Health Organization has concluded regarding second hand aerosol (SHA) "that while there are a limited number of studies in this area, it can be concluded that SHA is a new air contamination source for particulate matter, which includes fine and ultrafine particles, as well as 1,2-propanediol, some VOCs [volatile organic compounds], some heavy metals, and nicotine" and "[i]t is nevertheless reasonable to assume that the increased concentration of toxicants from SHA over background levels poses an increased risk for the health of all bystanders".[107] Public Health England has concluded that "international peer-reviewed evidence indicates that the risk to the health of bystanders from secondhand e-cigarette vapour is extremely low and insufficient to justify prohibiting e-cigarettes".[157] A systematic review concluded, "the absolute impact from passive exposure to EC [electronic cigarette] vapour has the potential to lead to adverse health effects. The risk from being passively exposed to EC vapour is likely to be less than the risk from passive exposure to conventional cigarette smoke."[158]

Nicotine, a key ingredient in e-liquids, is a highly addictive substance, on a level comparable to heroin and cocaine.[159] Nicotine stimulates regions of the cortex associated with reward, pleasure and reducing anxiety.[90] When nicotine intake stops, withdrawal symptoms include cravings for nicotine, anger/irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger or weight gain, and difficulty concentrating.[48][160] It is not clear whether e-cigarette use will decrease or increase overall nicotine addiction,[161] but the nicotine content in e-cigarettes is adequate to sustain nicotine dependence.[162]

The World Health Organization is concerned about addiction for non-smokers,[19] and the National Institute on Drug Abuse said e-cigarettes could maintain nicotine addiction in those who are attempting to quit.[163] The limited available data suggests that the likelihood of abuse from e-cigarettes is smaller than traditional cigarettes.[164] A 2014 systematic review found that the concerns that e-cigarettes could lead non-smokers to start smoking are unsubstantiated.[27] No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction,[132] but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.[75]

Many studies have focused on young people, since youthful experimentation with e-cigarettes could lead to lifelong addiction.[59] Various organizations, including the UATLD, the AAP and the FDA, have expressed concern that e-cigarette use could increase nicotine addiction in youth.[138][163][165][166][167][168][169] Although regular use of e-cigarettes is generally very low by people who have never smoked,[25] significant numbers of teenagers who have never smoked tobacco have experimented with e-cigarettes.[23] The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown,[147] as is the extent to which e-cigarette use could lead to addiction or substance dependence in youth.[147]

Smoking a traditional cigarette yields between 0.5 and 1.5 mg of nicotine,[162] but the nicotine content of the cigarette is only weakly correlated with the levels of nicotine in the smoker's bloodstream.[170] The amount of nicotine in the e-cigarette aerosol varies widely either from puff-to-puff or among products of the same company.[24] In practice e-cigarette users tend to reach lower blood nicotine concentrations than smokers, particularly when the users are inexperienced or using earlier-generation devices.[93] Nicotine in tobacco smoke is absorbed into the bloodstream rapidly, and e-cigarette vapor is relatively slow in this regard.[93] The concentration of nicotine in e-liquid ranges up to 36 mg/mL.[26] New EU regulations cap this at a maximum of 2% (20 mg/mL), but this is an arbitrary ceiling based on limited data.[8] In practice the nicotine concentration in an e-liquid is not a reliable guide to the amount of nicotine that reaches the bloodstream.[26]

The earliest e-cigarette can be traced to American Herbert A. Gilbert,[171] who in 1963 patented "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air".[172][173] This device produced flavored steam without nicotine.[173] The patent was granted in 1965.[174] Gilbert's invention was ahead of its time.[175] There were prototypes, but it received little attention[176] and was never commercialized[173] because smoking was still fashionable at that time.[177] Gilbert said in 2013 that today's electric cigarettes follow the basic design set forth in his original patent.[174]

Hon Lik, a Chinese pharmacist and inventor who worked as a research pharmacist for a company producing ginseng products, is credited with the invention of the modern e-cigarette.[30] Lik quit smoking after his father, also a heavy smoker, died of lung cancer.[30] In 2001, he thought of using a high frequency, piezoelectric ultrasound-emitting element to vaporize a pressurized jet of liquid containing nicotine.[178] This design creates a smoke-like vapor.[30] Lik said that using resistance heating obtained better results and the difficulty was to scale down the device to a small enough size.[178] Lik's invention was intended to be an alternative to smoking.[178]

The Ruyan e-cigar was first launched in China in 2004.

Hon Lik registered a patent for the modern e-cigarette design in 2003.[178] The e-cigarette was first introduced to the Chinese domestic market in 2004.[30] Many versions made their way to the U.S., sold mostly over the Internet by small marketing firms.[30] E-cigarettes entered the European market and the US market in 2006 and 2007.[50] The company that Lik worked for, Golden Dragon Holdings, registered an international patent in November 2007.[179] The company changed its name to Ruyan (如烟, literally "Resembling smoking") later the same month[180] and started exporting its products.[30] Many US and Chinese e-cig makers copied his designs illegally, so Lik has not received much financial reward for his invention (although some US manufacturers have compensated him through out of court settlements).[181] Ruyan later changed its company name to Dragonite International Limited.[180] Most e-cigarettes today use a battery-powered heating element rather than the earlier ultrasonic technology design.[117]

When e-cigarettes entered the international market, some users were dissatisfied with their performance,[182][183] and the e-cigarette continued to evolve from the first generation three-part device.[94] In 2007 British entrepreneurs Umer and Tariq Sheikh invented the cartomizer.[184] This is a mechanism that integrates the heating coil into the liquid chamber.[184] They launched this new device in the UK in 2008 under their Gamucci brand,[183] and the design is now widely adopted by most "cigalike" brands.[94] Other users tinkered with various parts to produce more satisfactory homemade devices, and the hobby of "modding" was born.[182] The first mod to replace the e-cigarette's case to accommodate a longer-lasting battery, dubbed the "screwdriver", was developed by Ted and Matt Rogers[182] in 2008.[97] Other enthusiasts built their own mods to improve functionality or aesthetics.[182] When pictures of mods appeared at online vaping forums many people wanted them, so some mod makers produced more for sale.[182]

The demand for customizable e-cigarettes prompted some manufacturers to produce devices with interchangeable components that could be selected by the user.[97] In 2009, Joyetech developed the eGo series[184] which offered the power of the screwdriver model and a user-activated switch to a wide market.[97] The clearomizer was invented in 2009.[184] Originating from the cartomizer design, it contained the wicking material, an e-liquid chamber, and an atomizer coil within a single clear component.[184] The clearomizer allows the user to monitor the liquid level in the device.[184] Soon after the clearomizer reached the market, replaceable atomizer coils and variable voltage batteries were introduced.[184] Clearomizers and eGo batteries became the best-selling customizable e-cigarette components in early 2012.[97]

International tobacco companies dismissed e-cigarettes as a fad at first.[185] However, recognizing the development of a potential new market sector that could render traditional tobacco products obsolete,[186] they began to produce and market their own brands of e-cigarettes and acquire existing e-cigarette companies.[187]blu eCigs, a prominent US e-cigarette manufacturer, was acquired by Lorillard Inc. in 2012.[188]British American Tobacco was the first tobacco business to sell e-cigarettes in the UK.[189] They launched Vype in 2013, while Imperial Tobacco's Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite International Limited for $US 75 million in 2013 and launched Puritane in partnership with Boots UK.[190] On 1 October 2013 Lorillard Inc. acquired another e-cigarette company, this time the UK based company SKYCIG.[191] SKY was rebranded as blu.[192] On 3 February 2014, Altria Group, Inc. acquired popular electronic cigarette brand Green Smoke for $110 million.[193] The deal was finalized in April 2014 for $110 million with $20 million in incentive payments.[193] Altria also markets its own e-cigarette, the MarkTen, while Reynolds American has entered the sector with its Vuse product.[187] Philip Morris, the world's largest tobacco firm, purchased UK's Nicocigs in June 2014.[194] On 30 April 2015, Japan Tobacco bought the US Logic e-cigarette brand.[195] Japan Tobacco also bought the UK E-Lites brand in June 2014.[195] On 15 July 2014, Lorillard sold blu to Imperial Tobacco as part of a deal for $7.1 billion.[196]

In 2014, dollar sales of customizable e-cigarettes and e-liquid surpassed sales of cigalikes in the US, despite the fact that customizables are less expensive.[197]

Consumers of e-cigarettes, sometimes called "vapers", have shown passionate support for e-cigarettes that other nicotine replacement therapies did not receive.[26][198] This suggests e-cigarettes have potential mass appeal that could challenge combustible tobacco's market position.[26]

A subculture of "vapers" has emerged.[198][199] Members of this emerging subculture often see e-cigarettes as a safer alternative to smoking,[25] and some view it as a hobby.[200] The online forum Electronic Cigarette Forum was one of the first major communities.[182] It and other online forums, such as UKVaper.org, were the origins of the hobby of modding.[182] There are also groups on Facebook and Reddit.[201] Online forums based around modding have grown in the vaping community.[202] Vapers energetically embrace activities associated with e-cigarettes and sometimes act as unpaid evangelists according to a 2014 review.[83] A 2014 Postgraduate Medical Journal editorial stated that e-cigarette companies have a substantial online presence, as well as many individual vapers who blog and tweet about e-cigarette related products.[203] The editorial stated that vapers "also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks".[203] A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda.[23] The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws.[23] The same review said this is similar to tobacco industry activity going back to the 1980s.[23] These approaches were used in Europe to minimize the EU Tobacco Product Directive in October 2013.[23] True grassroots lobbying also influenced the TPD decision.[204]Rebecca Taylor, a member of the European Parliament, stated, "to say it's an orchestrated campaign is absolute rubbish."[204] Contempt for "big tobacco" is part of vaping culture.[205][206]

E-cigarette user blowing a cloud of aerosol (vapor). The activity is known as cloud-chasing.[207]

Large gatherings of vapers, called vape meets, take place around the US.[198] They focus on e-cig devices, accessories, and the lifestyle that accompanies them.[198] Vapefest, which started in 2010, is an annual show hosted by different cities.[201] People attending these meetings are usually enthusiasts that use specialized, community-made products not found in convenience stores or gas stations.[198] These products are mostly available online or in dedicated "vape" storefronts where mainstream e-cigarettes brands from the tobacco industry and larger e-cig manufacturers are not as popular.[208] Some vape shops have a vape bar where patrons can test out different e-liquids and socialize.[209] The Electronic Cigarette Convention in North America which started in 2013, is an annual show where companies and consumers meet up.[210]

A subclass of vapers configure their atomizers to produce large amounts of vapor by using low-resistance heating coils.[211] This practice is called "cloud-chasing"[212][213] By using a coil with very low resistance, the batteries are stressed to a potentially unsafe extent.[212] This could present a risk of dangerous battery failures.[212] As vaping comes under increased scrutiny, some members of the vaping community have voiced their concerns about cloud-chasing, claiming the practice gives vapers a bad reputation when doing it in public.[214] The Oxford Dictionaries' word of the year for 2014 was "vape".[215]

Main articles: Regulation of electronic cigarettes and List of vaping bans in the United States A no smoking or vaping sign from the US.

Regulation of e-cigarettes varies across countries and states, ranging from no regulation to banning them entirely.[216] Others have introduced strict restrictions and some have licensed devices as medicines such as in the UK.[217] As of 2015[update], around two thirds of major nations have regulated e-cigarettes in some way.[218] Because of the potential relationship with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries.[35] The companies that make e-cigarettes have been pushing for laws that support their interests.[219] In 2016 the US Department of Transportation banned the use of e-cigarettes on commercial flights.[220] This regulation applies to all flights to and from the US.[220]

The legal status of e-cigarettes is currently pending in many countries.[23] Many countries such as Brazil, Singapore, the Seychelles, Uruguay, and Norway have banned e-cigarettes.[217] In Canada, they are technically illegal to sell, as no nicotine-containing e-fluid is approved by Health Canada, but this is generally unenforced and they are commonly available for sale Canada-wide.[221] In the US and the UK, the use and sale to adults of e-cigarettes are legal.[222]:US[223]:UK As of August 8, 2016, the FDA extended its regulatory power to include e-cigarettes.[37] Under this ruling the FDA will evaluate certain issues, including ingredients, product features and health risks, as well their appeal to minors and non-users.[224] The FDA rule also bans access to minors.[224] A photo ID is required to buy e-cigarettes,[225] and their sale in all-ages vending machines is not permitted.[224] In May 2016 the FDA used its authority under the Family Smoking Prevention and Tobacco Control Act to deem e-cigarette devices and e-liquids to be tobacco products, which meant it intended to regulate the marketing, labelling, and manufacture of devices and liquids; vape shops that mix e-liquids or make or modify devices were considered manufacturing sites that needed to register with FDA and comply with good manufacturing practice regulation.[16] E-cigarette and tobacco companies have recruited lobbyists in an effort to prevent the FDA from evaluating e-cigarette products or banning existing products already on the market.[226]

In February 2014 the European Parliament passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging.[36][227] In April 2014 the FDA published proposed regulations for e-cigarettes along similar lines.[228][229] In the US some states tax e-cigarettes as tobacco products, and some state and regional governments have broadened their indoor smoking bans to include e-cigarettes.[76] As of 9 October 2015, at least 48 states and 2 territories banned e-cigarette sales to minors.[230]

E-cigarettes have been listed as drug delivery devices in several countries because they contain nicotine, and their advertising has been restricted until safety and efficacy clinical trials are conclusive.[231] Since they do not contain tobacco, television advertising in the US is not restricted.[232] Some countries have regulated e-cigarettes as a medical product even though they have not approved them as a smoking cessation aid.[233] A 2014 review stated the emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public and recommended that e-cigarettes should be regulated to protect consumers.[134] It added, "heavy regulation by restricting access to e-cigarettes would just encourage continuing use of much unhealthier tobacco smoking."[134] A 2014 review said these products should be considered for regulation in view of the "reported adverse health effects".[233]

A 2014 review said, "the e-cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to promote cigarettes in the 1950s and 1960s."[23] E-cigarettes and nicotine are regularly promoted as safe and beneficial in the media and on brand websites.[77] While advertising of tobacco products is banned in most countries, television and radio e-cigarette advertising in some countries may be indirectly encouraging traditional cigarette smoking.[23] There is no evidence that the cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some claiming to want to cooperate in "harm reduction".[23] In the US, six large e-cigarette businesses spent $59.3 million on promoting e-cigarettes in 2013.[234] Easily circumvented age verification at company websites enables young people to access and be exposed to marketing for e-cigarettes.[73]

A national US television advertising campaign starred Steven Dorff exhaling a "thick flume" of what the ad describes as "vapor, not tobacco smoke", exhorting smokers with the message "We are all adults here, it's time to take our freedom back."[235] The ads, in a context of longstanding prohibition of tobacco advertising on TV, were criticized by organizations such as Campaign for Tobacco-Free Kids as undermining anti-tobacco efforts.[235] Cynthia Hallett of Americans for Non-Smokers' Rights described the US advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable".[235] University of Pennsylvania communications professor Joseph Cappella stated that the setting of the ad near an ocean was meant to suggest an association of clean air with the nicotine product.[235] In 2012 and 2013, e-cigarette companies advertised to a large television audience in the US which included 24 million youth.[236] The channels on which e-cigarette advertising reached the largest numbers of youth (ages 12–17) were AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.[236]

A 2014 review said e-cigarettes are aggressively promoted, mostly via the internet, as a healthy alternative to smoking in the US.[32]Celebrity endorsements are used to encourage e-cigarette use.[78] "Big tobacco" markets e-cigarettes to young people,[237] with industry strategies including cartoon characters and candy flavors to sell e-cigarettes.[238] E-cigarette companies commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as scientists have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum.[57] The assertion that e-cigarette emit "only water vapor" is false because the evidence indicates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and organic volatile compounds, in addition to particulates.[239]

Vaping stand, London shopping centre.

The number of e-cigarettes sold increased every year[117] from 2003 to 2015, when a slowdown in the growth in usage occurred in both the US and the UK.[45][46] As of 2014[update] there were at least 466 e-cigarette brands.[49] Worldwide e-cigarette sales in 2014 were around US$7 billion.[240] Approximately 30–50% of total e-cigarettes sales are handled on the internet.[32]

As of 2015[update] most e-cigarette devices were made in China,[31] mainly in Shenzhen.[241][242] Chinese companies' market share of e-liquid is low.[243]

In the US, tobacco producers have a significant share of the e-cigarette market.[59][244] As of 2015[update], 80% of all e-cigarette sales in convenience stores in the U.S. were products made by tobacco companies.[245] According to Nielsen Holdings, convenience store e-cigarette sales in the US went down for the first time during the four-week period ending on 10 May 2014.[246] Wells Fargo analyst Bonnie Herzog attributes this decline to a shift in consumers' behavior, buying more specialized devices or what she calls "vapor/tank/mods (VTMs)" that are not tracked by Nielsen.[246] Wells Fargo estimated that VTMs accounted for 57% of the 3.5 billion dollar market in the US for vapor products in 2015.[247] In 2014, the Smoke-Free Alternatives Trade Association estimated that there were 35,000 vape shops in the US, more than triple the number a year earlier.[248] However the 2015 slowdown in market growth affected VTMs as well.[45]

In Canada, e-cigarettes had an estimated value of 140 million CAD in 2015.[249] There are numerous e-cigarette retail shops in Canada.[250] A 2014 audit of retailers in four Canadian cities found that 94% of grocery stores, convenience stores, and tobacconist shops which sold e-cigarettes sold nicotine-free varieties only, while all vape shops stocked at least one nicotine-containing product.[251]

In the UK in 2015 the "most prominent brands of cigalikes" were owned by tobacco companies, but except for one model all the tank types came from "non-tobacco industry companies".[105] However some tobacco industry products, while using prefilled cartridges, resemble tank models.[105]

France's electronic cigarette market was estimated by Groupe Xerfi to be €130 million in 2015. Additionally, France's e-liquid market was estimated at €265 million.[252] In December 2015, there were 2,400 vape shops in France, 400 fewer than in March of the same year.[252] Industry organization Fivape said the reduction was due to consolidation, not to reduced demand.[252]

Other devices to deliver inhaled nicotine have been developed.[253] They aim to mimic the ritual and behavioral aspects of traditional cigarettes.[253]

British American Tobacco, through their subsidiary Nicoventures, licensed a nicotine delivery system based on existing asthma inhaler technology from UK-based healthcare company Kind Consumer.[254] In September 2014 a product based on this named Voke obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.[255]

Philip Morris International (PMI) bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University.[256] The technology is based on the chemical reaction between pyruvic acid and nicotine, which produces an inhalable nicotine pyruvate vapor.[257]

PAX Labs has developed vaporizers that heats the leaves of tobacco to deliver nicotine in a vapor.[258][259] On 1 June 2015, they introduced Juul a different type of e-cigarette which delivers 10 times as much nicotine as other e-cigarettes, equivalent to an actual cigarette puff.[260]

BLOW started selling e-hookahs, an electronic version of the hookah, in 2014.[261] Several companies including Canada's Eagle Energy Vapor are selling caffeine-based e-cigarettes instead of nicotine.[262]

  1. ^ a b Sullum, Jacob (27 Aug 2015), "Wacky British Idea: Why Not Tell The Truth About E-Cigarettes?", Forbes 
  2. ^ a b c d WHO (2014), Electronic nicotine delivery systems: FCTC/COP/6/10 Rev.1 (PDF), Moscow: World Health Organization, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Sixth session, 13–18 October 2014 
  3. ^ a b "Cambridge study raises fears over e-cigarette adverts for children", Cambridge News, 18 Jan 2016 
  4. ^ Lam on behalf of the Asian-Pacific Society of Respirology; et al. (2014), "Electronic cigarettes: ‘Vaping’ has unproven benefits and potential harm", Respirology, 19: 945–947, PMID 25196968, doi:10.1111/resp.12374 
  5. ^ a b Millar et al. (20 Mar 2016), "Consumer Product Safety Commission Gains New Authority Over Some Nicotine-Containing E-Liquid Packages", The National Law Review CS1 maint: Uses authors parameter (link)
  6. ^ a b c d e f g h i j McRobbie, Hayden; Bullen, Chris; Hartmann-Boyce, Jamie; Hajek, Peter; McRobbie, Hayden (2014). "Electronic cigarettes for smoking cessation and reduction". The Cochrane Library. 12: CD010216. PMID 25515689. doi:10.1002/14651858.CD010216.pub2. 
  7. ^ V.Courtney Broaddus, Robert C Mason, Joel D Ernst, Talmadge E King Jr., Stephen C. Lazarus, John F. Murray, Jay A. Nadel, Arthur Slutsky, Michael Gotway (2015). Murray & Nadel's Textbook of Respiratory Medicine. Elsevier Health Sciences. p. 820. ISBN 0323261930. CS1 maint: Uses authors parameter (link)
  8. ^ a b c d e f g h Ebbert, Jon O.; Agunwamba, Amenah A.; Rutten, Lila J. (2015). "Counseling Patients on the Use of Electronic Cigarettes". Mayo Clinic Proceedings. 90 (1): 128–134. ISSN 0025-6196. PMID 25572196. doi:10.1016/j.mayocp.2014.11.004. 
  9. ^ a b c d e f g Siu, A.L. (22 September 2015). "Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement.". Annals of Internal Medicine. 163: 622–34. PMID 26389730. doi:10.7326/M15-2023. 
  10. ^ a b Harrell, P.T.; Simmons, V.N.; Correa, J.B.; Padhya, T.A.; Brandon, T.H. (4 June 2014). "Electronic Nicotine Delivery Systems ("E-cigarettes"): Review of Safety and Smoking Cessation Efficacy.". Otolaryngology—head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 151: 381–393. PMC 4376316 . PMID 24898072. doi:10.1177/0194599814536847. 
  11. ^ Golub, Justin S.; Samy, Ravi N. (2015). "Preventing or reducing smoking-related complications in otologic and neurotologic surgery". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (5): 334–340. ISSN 1068-9508. PMID 26339963. doi:10.1097/MOO.0000000000000184. 
  12. ^ a b c d McNeill, A. (August 2015). "E-cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. pp. 77–78. 
  13. ^ a b c d e f Rahman MA, Hann N, Wilson A, Worrall-Carter L (2014). "Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues". Tob Induc Dis. 12 (1): 21. PMC 4350653 . PMID 25745382. doi:10.1186/1617-9625-12-21. CS1 maint: Uses authors parameter (link)
  14. ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016. Retrieved 29 May 2016. 
  15. ^ a b c d Royal College of Physicians. "Nicotine without smoke: Tobacco harm reduction". rcplondon.ac.uk. Retrieved 8 May 2016. 
  16. ^ a b c "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. US Food and Drug Administration. 81 (90): 28974–29106. 10 May 2016. 
  17. ^ Nutt, DJ; Phillips, LD; Balfour, D; Curran, HV; Dockrell, M; Foulds, J; Fagerstrom, K; Letlape, K; Milton, A; Polosa, R; Ramsey, J; Sweanor, D (2014). "Estimating the harms of nicotine-containing products using the MCDA approach.". European Addiction Research. 20 (5): 218–25. PMID 24714502. doi:10.1159/000360220. 
  18. ^ a b c Caponnetto P.; Russo C.; Bruno C.M.; Alamo A.; Amaradio M.D.; Polosa R. (Mar 2013). "Electronic cigarette: a possible substitute for cigarette dependence". Monaldi archives for chest disease. 79 (1): 12–19. PMID 23741941. doi:10.4081/monaldi.2013.104. 
  19. ^ a b c d e f g h i j k WHO. "Electronic nicotine delivery systems" (PDF). pp. 1–13. Retrieved 28 August 2014. 
  20. ^ a b "E-Cigarette Use Among Youth and Young Adults A Report of the Surgeon General: Fact Sheet" (PDF). United States Department of Health and Human Services. Surgeon General of the United States. 2016.  This article incorporates text from this source, which is in the public domain.
  21. ^ Soneji, S; Barrington-Trimis, J; Wills, T (26 June 2017). "Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults, A Systematic Review and Meta-analysis". JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1488. 
  22. ^ McNeill, A, PH. "Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note". gov.uk. Public Health England. Retrieved 27 May 2016. 
  23. ^ a b c d e f g h i j k l m n o p q r s t u Grana, R; Benowitz, N; Glantz, SA (13 May 2014). "E-cigarettes: a scientific review.". Circulation. 129 (19): 1972–86. PMC 4018182 . PMID 24821826. doi:10.1161/circulationaha.114.007667. 
  24. ^ a b c d e f Cheng, T. (2014). "Chemical evaluation of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii11–ii17. ISSN 0964-4563. PMC 3995255 . PMID 24732157. doi:10.1136/tobaccocontrol-2013-051482. 
  25. ^ a b c d e f g h i Hajek, P.; Etter, J.F.; Benowitz, N.; Eissenberg, T.; McRobbie, H. (31 July 2014). "Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit". Addiction (Abingdon, England). 109 (11): 1801–10. PMC 4487785 . PMID 25078252. doi:10.1111/add.12659. 
  26. ^ a b c d e f g h Britton, John; Bogdanovica, Ilze (15 May 2014). "Electronic cigarettes – A report commissioned by Public Health England" (PDF). Public Health England. 
  27. ^ a b c d e f g Farsalinos, K.E.; Polosa, R. (2014). "Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review". Therapeutic Advances in Drug Safety. 5 (2): 67–86. ISSN 2042-0986. PMC 4110871 . PMID 25083263. doi:10.1177/2042098614524430. 
  28. ^ a b c Burstyn, Igor (2014). "Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks". BMC Public Health. 14 (1): 18. ISSN 1471-2458. PMC 3937158 . PMID 24406205. doi:10.1186/1471-2458-14-18. 
  29. ^ a b c "E-cigarettes: an emerging public health consensus". UK: Public Health England. 2015. 
  30. ^ a b c d e f g Barbara Demick (25 April 2009). "A high-tech approach to getting a nicotine fix". Los Angeles Times. 
  31. ^ a b c Alawsi, F.; Nour, R.; Prabhu, S. (2015). "Are e-cigarettes a gateway to smoking or a pathway to quitting?". BDJ. 219 (3): 111–115. ISSN 0007-0610. PMID 26271862. doi:10.1038/sj.bdj.2015.591. 
  32. ^ a b c d e f Rom, Oren; Pecorelli, Alessandra; Valacchi, Giuseppe; Reznick, Abraham Z. (2014). "Are E-cigarettes a safe and good alternative to cigarette smoking?". Annals of the New York Academy of Sciences. 1340 (1): 65–74. ISSN 0077-8923. PMID 25557889. doi:10.1111/nyas.12609. 
  33. ^ a b "E-cigarette use triples among middle and high school students in just one year". CDC. Retrieved 15 December 2015. 
  34. ^ a b c "Use of electronic cigarettes (vapourisers) among adults in Great Britain" (PDF). ASH UK. May 2015. 
  35. ^ a b Kim, Ki-Hyun; Kabir, Ehsanul; Jahan, Shamin Ara (2016). "Review of electronic cigarettes as tobacco cigarette substitutes: their potential human health impact". Journal of Environmental Science and Health, Part C: 00–00. ISSN 1059-0501. PMID 27635466. doi:10.1080/10590501.2016.1236604. 
  36. ^ a b "Questions & Answers: New rules for tobacco products". European Commission. 26 February 2014. 
  37. ^ a b "FDA's New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products". US Department of Health and Human Services. US Food and Drug Administration. 12 August 2016. 
  38. ^ a b "Backgrounder on WHO report on regulation of e-cigarettes and similar products". 26 August 2014. Retrieved 2 June 2015. 
  39. ^ editor (13 Aug 2015), "Tasty E-Cigs Popular, Scientifically Uncertain", WGCU News NPR 
  40. ^ Kahn, Steven (18 Dec 2015), "The Best Electronic Cigarettes For Beginners", The Gazette Review 
  41. ^ Keenan et al. (9 Sep 2015), "Vape Culture Attracts Teens, Poses Harmful Risks", The Huffington Post CS1 maint: Uses authors parameter (link)
  42. ^ "Public consultation on legislation in relation to the sale of tobacco products and non-medicinal nicotine delivery systems, including e-cigarettes". Department of Health (Ireland). 2 December 2014. Retrieved 4 October 2016. 
  43. ^ Michael Felberbaum (11 June 2013). "Marlboro Maker To Launch New Electronic Cigarette". The Huffington Post. 
  44. ^ a b Schraufnagel, Dean E.; Blasi, Francesco; Drummond, M. Bradley; Lam, David C. L.; Latif, Ehsan; Rosen, Mark J.; Sansores, Raul; Van Zyl-Smit, Richard (2014). "Electronic Cigarettes. A Position Statement of the Forum of International Respiratory Societies". American Journal of Respiratory and Critical Care Medicine. 190 (6): 611–618. ISSN 1073-449X. PMID 25006874. doi:10.1164/rccm.201407-1198PP. 
  45. ^ a b c Mickle, Tripp (17 November 2015). "E-cig sales rapidly lose steam". E-Cigarette Sales Rapidly Lose Steam. Retrieved 6 December 2015. 
  46. ^ a b West, Robert; Beard, Emma; Brown, Jamie (10 August 2015). "Electronic cigarettes in England – latest trends (STS140122)". Smoking in England. Retrieved 6 December 2015. 
  47. ^ a b c d e Carroll Chapman, SL; Wu, LT (18 Mar 2014). "E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.". Journal of Psychiatric Research. 54: 43–54. PMC 4055566 . PMID 24680203. doi:10.1016/j.jpsychires.2014.03.005. 
  48. ^ a b c Bullen, Christopher (2014). "Electronic Cigarettes for Smoking Cessation". Current Cardiology Reports. 16 (11): 538. ISSN 1523-3782. PMID 25303892. doi:10.1007/s11886-014-0538-8. 
  49. ^ a b Born, H.; Persky, M.; Kraus, D.H.; Peng, R.; Amin, M.R.; Branski, R.C. (2015). "Electronic Cigarettes: A Primer for Clinicians". Otolaryngology – Head and Neck Surgery. 153: 5–14. ISSN 0194-5998. PMID 26002957. doi:10.1177/0194599815585752. 
  50. ^ a b c d e f g h i Pepper, J. K.; Brewer, N. T. (2013). "Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review". Tobacco Control. 23 (5): 375–384. ISSN 0964-4563. PMC 4520227 . PMID 24259045. doi:10.1136/tobaccocontrol-2013-051122. 
  51. ^ Suter, Melissa A.; Mastrobattista, Joan; Sachs, Maike; Aagaard, Kjersti (2015). "Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (3): 186–195. ISSN 1542-0752. PMC 4830434 . PMID 25366492. doi:10.1002/bdra.23333. 
  52. ^ Franck, C.; Budlovsky, T.; Windle, S.B.; Filion, K. B.; Eisenberg, M.J. (2014). "Electronic Cigarettes in North America: History, Use, and Implications for Smoking Cessation". Circulation. 129 (19): 1945–1952. ISSN 0009-7322. PMID 24821825. doi:10.1161/CIRCULATIONAHA.113.006416. 
  53. ^ Charlotte A. Schoenborn, Renee M. Gindi (October 2015). "Electronic Cigarette Use Among Adults: United States, 2014" (PDF). Centers for Disease Control and Prevention. pp. 1–8. CS1 maint: Uses authors parameter (link)
  54. ^ a b c d Delnevo, Cristine D.; Giovenco, Daniel P.; Steinberg, Michael B.; Villanti, Andrea C.; Pearson, Jennifer L.; Niaura, Raymond S.; Abrams, David B. (2 November 2015). "Patterns of Electronic Cigarette Use Among Adults in the United States". Nicotine & Tobacco Research. 18: ntv237. doi:10.1093/ntr/ntv237. 
  55. ^ Volkow, Nora (August 2015). "Teens Using E-cigarettes More Likely to Start Smoking Tobacco". National Institute on Drug Abuse. 
  56. ^ a b Lauterstein, Dana; Hoshino, Risa; Gordon, Terry; Watkins, Beverly-Xaviera; Weitzman, Michael; Zelikoff, Judith (2014). "The Changing Face of Tobacco Use Among United States Youth". Current Drug Abuse Reviews. 7 (1): 29–43. ISSN 1874-4737. PMC 4469045 . PMID 25323124. doi:10.2174/1874473707666141015220110. 
  57. ^ a b Hildick-Smith, Gordon J.; Pesko, Michael F.; Shearer, Lee; Hughes, Jenna M.; Chang, Jane; Loughlin, Gerald M.; Ipp, Lisa S. (2015). "A Practitioner's Guide to Electronic Cigarettes in the Adolescent Population". Journal of Adolescent Health. 57: 574–9. ISSN 1054-139X. PMID 26422289. doi:10.1016/j.jadohealth.2015.07.020. 
  58. ^ Sabrina Tavernise (17 April 2015). "Use of e-cigarettes rising sharply among teenagers". Boston Globe. 
  59. ^ a b c d Schraufnagel, Dean E. (2015). "Electronic Cigarettes: Vulnerability of Youth". Pediatric Allergy, Immunology, and Pulmonology. 28 (1): 2–6. ISSN 2151-321X. PMC 4359356 . PMID 25830075. doi:10.1089/ped.2015.0490. 
  60. ^ "Monitoring the Future Survey, Overview of Findings 2015". National Institute on Drug Abuse. Retrieved 10 March 2016. 
  61. ^ Arrazola, RA; Neff, LJ; Kennedy, SM; Holder-Hayes, E; Jones, CD (14 November 2014). "Tobacco Use Among Middle and High School Students — United States, 2013". MMWR Morb. Mortal. Wkly. Rep. 63 (45): 1021–1026. PMID 24699766. 
  62. ^ a b Cooke, Andrew; Fergeson, Jennifer; Bulkhi, Adeeb; Casale, Thomas B. (2015). "The Electronic Cigarette: The Good, the Bad, and the Ugly". The Journal of Allergy and Clinical Immunology: In Practice. 3 (4): 498–505. ISSN 2213-2198. PMID 26164573. doi:10.1016/j.jaip.2015.05.022. 
  63. ^ Centers for Disease Control and Prevention (CDC) (November 2013). "Tobacco product use among middle and high school students—United States, 2011 and 2012". MMWR Morb. Mortal. Wkly. Rep. 62 (45): 893–7. PMID 24226625. 
  64. ^ a b McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. Retrieved 19 August 2015. 
  65. ^ a b c "Use of electronic cigarettes in Great Britain" (PDF). ASH. ASH. July 2014. Retrieved 18 September 2014. 
  66. ^ "Over 2 million Britons now regularly use electronic cigarettes". ASH UK. 28 April 2014. Retrieved 30 May 2014. 
  67. ^ McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. pp. 31–34. Retrieved 25 August 2015. 
  68. ^ Moore, G. F.; Littlecott, H. J.; Moore, L.; Ahmed, N.; Holliday, J. (2014). "E-cigarette use and intentions to smoke among 10-11-year-old never-smokers in Wales". Tobacco Control. 25: 147–52. ISSN 0964-4563. PMC 4789807 . PMID 25535293. doi:10.1136/tobaccocontrol-2014-052011. 
  69. ^ a b c "Prévalence, comportements d'achat et d'usage, motivations des utilisateurs de la cigarette électronique" (PDF). Observatoire Français des Drogues et des Toxicomanies. 12 February 2014. Retrieved 28 March 2014. 
  70. ^ a b c Brandon, T.H.; Goniewicz, M.L.; Hanna, N.H.; Hatsukami, D.K.; Herbst, R.S.; Hobin, J.A.; Ostroff, J.S.; Shields, P.G.; Toll, B.A.; Tyne, C.A.; Viswanath, K.; Warren, G.W. (2015). "Electronic Nicotine Delivery Systems: A Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology" (PDF). Clinical Cancer Research. 21: 514–525. ISSN 1078-0432. PMID 25573384. doi:10.1158/1078-0432.CCR-14-2544. 
  71. ^ Zhong, Jieming; Cao, Shuangshuang; Gong, Weiwei; Fei, Fangrong; Wang, Meng (3 May 2016). "Electronic Cigarettes Use and Intention to Cigarette Smoking among Never-Smoking Adolescents and Young Adults: A Meta-Analysis". International Journal of Environmental Research and Public Health. 13 (5): 465. doi:10.3390/ijerph13050465. 
  72. ^ a b "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original on 6 November 2014. CS1 maint: BOT: original-url status unknown (link)
  73. ^ a b c Grana R.A., Ling P.M. (2014). ""Smoking revolution": a content analysis of electronic cigarette retail websites". Am J Prev Med. 46 (4): 395–403. PMC 3989286 . PMID 24650842. doi:10.1016/j.amepre.2013.12.010. CS1 maint: Uses authors parameter (link)
  74. ^ a b Tomashefski, A (21 March 2016). "The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review.". Journal of the American Association of Nurse Practitioners. PMID 26997487. doi:10.1002/2327-6924.12358. 
  75. ^ a b c d e Orellana-Barrios, Menfil A.; Payne, Drew; Mulkey, Zachary; Nugent, Kenneth (2015). "Electronic cigarettes-a narrative review for clinicians". The American Journal of Medicine. 128: 674–81. ISSN 0002-9343. PMID 25731134. doi:10.1016/j.amjmed.2015.01.033. 
  76. ^ a b Crowley, Ryan A. (2015). "Electronic Nicotine Delivery Systems: Executive Summary of a Policy Position Paper From the American College of Physicians". Annals of Internal Medicine. 162 (8): 583–4. ISSN 0003-4819. PMID 25894027. doi:10.7326/M14-2481. 
  77. ^ a b c England, Lucinda J.; Bunnell, Rebecca E.; Pechacek, Terry F.; Tong, Van T.; McAfee, Tim A. (2015). "Nicotine and the Developing Human". American Journal of Preventive Medicine. 49: 286–93. ISSN 0749-3797. PMC 4594223 . PMID 25794473. doi:10.1016/j.amepre.2015.01.015. 
  78. ^ a b Linda Bauld; Kathryn Angus; Marisa de Andrade (May 2014). "E-cigarette uptake and marketing" (PDF). Public Health England. pp. 1–19. 
  79. ^ Kong, G.; Morean, M.E.; Cavallo, D.A.; Camenga, D.R.; Krishnan-Sarin, S. (2014). "Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults". Nicotine & Tobacco Research. 17: 847–54. ISSN 1462-2203. PMC 4674436 . PMID 25481917. doi:10.1093/ntr/ntu257. 
  80. ^ "Heart and Stroke Foundation: E-cigarettes in Canada". Heart and Stroke Foundation. 
  81. ^ Kevin Chatham-Stephens (20 October 2014). "Young Children and e-Cigarette Poisoning". Medscape. 
  82. ^ a b Yingst, J. M.; Veldheer, S.; Hrabovsky, S.; Nichols, T. T.; Wilson, S. J.; Foulds, J. (2015). "Factors associated with electronic cigarette users' device preferences and transition from first generation to advanced generation devices.". Nicotine Tob Res. 17: 1242–6. ISSN 1462-2203. PMC 4592341 . PMID 25744966. doi:10.1093/ntr/ntv052. 
  83. ^ 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)
  84. ^ a b c d e f g h i Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015-08-01). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. ISSN 1660-4601. PMC 4555324 . PMID 26308021. doi:10.3390/ijerph120809988. 
  85. ^ Abuse, National Institute on Drug. "Electronic Cigarettes (e-Cigarettes)". drugabuse.gov. Retrieved 2016-01-27. 
  86. ^ Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015-08-01). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. ISSN 1661-7827. PMC 4555324 . PMID 26308021. doi:10.3390/ijerph120809988. 
  87. ^ "Electronic Cigarette Fires and Explosions" (PDF). U.S. Fire Administration. 2014. pp. 1–11. 
  88. ^ "What is an e-Cigarette MOD E-cig 101". 19 February 2014. 
  89. ^ "Vaper Talk – The Vaper's Glossary". Spinfuel eMagazine. 5 July 2013. Retrieved 18 November 2014. 
  90. ^ a b c Rowell, Temperance R.; Tarran, Robert (2015). "Will Chronic E-Cigarette Use Cause Lung Disease?". American Journal of Physiology. Lung Cellular and Molecular Physiology. 309: ajplung.00272.2015. ISSN 1040-0605. PMC 4683316 . PMID 26408554. doi:10.1152/ajplung.00272.2015. 
  91. ^ a b c Caponnetto, Pasquale; Campagna, Davide; Papale, Gabriella; Russo, Cristina; Polosa, Riccardo (2012). "The emerging phenomenon of electronic cigarettes". Expert Review of Respiratory Medicine. 6 (1): 63–74. ISSN 1747-6348. PMID 22283580. doi:10.1586/ers.11.92. 
  92. ^ Glasser, A. M.; Cobb, C. O.; Teplitskaya, L.; Ganz, O.; Katz, L.; Rose, S. W.; Feirman, S.; Villanti, A. C. (2015). "Electronic nicotine delivery devices, and their impact on health and patterns of tobacco use: a systematic review protocol". BMJ Open. 5 (4): e007688–e007688. ISSN 2044-6055. PMC 4420972 . PMID 25926149. doi:10.1136/bmjopen-2015-007688. 
  93. ^ a b c d Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, Voudris V (2014). "Nicotine absorption from electronic cigarette use: Comparison between first and new-generation devices". Scientific Reports. 4: 4133. PMC 3935206 . PMID 24569565. doi:10.1038/srep04133. 
  94. ^ a b c Bhatnagar, A.; Whitsel, L. P.; Ribisl, K. M.; Bullen, C.; Chaloupka, F.; Piano, M.R.; Robertson, R. M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "AHA Policy Statement - Electronic Cigarettes". Circulation. 130 (16): 1418–1436. PMID 25156991. doi:10.1161/cir.0000000000000107.  Archive
  95. ^ Hayden McRobbie (2014). "Electronic cigarettes" (PDF). National Centre for Smoking Cessation and Training. pp. 1–16. 
  96. ^ Konstantinos Farsalinos. "Electronic cigarette evolution from the first to fourth generation and beyond" (PDF). gfn.net.co. Global Forum on Nicotine. p. 23. Retrieved 23 September 2015. 
  97. ^ a b c d e Garner, Charles; Stevens, Robert (February 2014). "A Brief Description of History, Operation and Regulation" (PDF). Coresta. Retrieved 21 February 2016. 
  98. ^ a b c Oh, Anne Y.; Kacker, Ashutosh (December 2014). "Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes?: Review on e-cigarette vapor versus tobacco smoke". The Laryngoscope. 124 (12): 2702–2706. PMID 25302452. doi:10.1002/lary.24750. 
  99. ^ Jimenez Ruiz, CA; Solano Reina, S; de Granda Orive, JI; Signes-Costa Minaya, J; de Higes Martinez, E; Riesco Miranda, JA; Altet Gómez, N; Lorza Blasco, JJ; Barrueco Ferrero, M; de Lucas Ramos, P (August 2014). "The electronic cigarette. Official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes.". Archivos de bronconeumologia. 50 (8): 362–7. PMID 24684764. doi:10.1016/j.arbres.2014.02.006. 
  100. ^ a b John Reid Blackwell. "Avail Vapor offers glimpse into the 'art and science' of e-liquids". Richmond Times-Dispatch. Retrieved 23 November 2015. 
  101. ^ E-Liquid Manufacturing Standards (PDF). US: AMERICAN E-LIQUID MANUFACTURING STANDARDS ASSOCIATION (AEMSA). 2015. pp. 1–13. 
  102. ^ "More than a quarter-million youth who had never smoked a cigarette used e-cigarettes in 2013". Centers for Disease Control and Prevention. Retrieved 8 July 2015. 
  103. ^ a b c Framework Convention Alliance on Tobacco Control. "FCA Policy briefing Electronic Nicotine Delivery Systems" (PDF). fctc.org. Retrieved 2 March 2016. 
  104. ^ a b "Electronic Cigarettes (e-Cigarettes)". US Food and Drug Administration. Retrieved 6 November 2014. 
  105. ^ a b c d McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 15. Retrieved 24 August 2015. 
  106. ^ National Centre for Smoking Cessation and Training. "Electronic cigarettes: A briefing for stop smoking services". ncsct.co.uk. Retrieved 2 March 2016. 
  107. ^ a b WHO (August 2016). "Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS)" (PDF). pp. 1–11. 
  108. ^ "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. Retrieved 6 November 2014. 
  109. ^ a b McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 76. Retrieved 19 August 2015. 
  110. ^ a b "Electronic cigarettes". Smokefree NHS. Are e-cigarettes safe to use?. Retrieved 28 October 2015. 
  111. ^ "Stop smoking treatments". UK National Health Service. Retrieved 6 November 2014. 
  112. ^ Royal College of Physicians. "Promote e-cigarettes widely as substitute for smoking says new RCP report". rcplondon.ac.uk. Retrieved 7 May 2017. 
  113. ^ "E-cigarette Ads and Youth". Centers for Disease Control and Prevention. Retrieved 26 January 2016. 
  114. ^ "Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions". United States Preventive Services Task Force. Retrieved 3 March 2016. 
  115. ^ "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. August 2015. Retrieved 19 April 2016. 
  116. ^ Farber HJ, Walley SC, Groner JA, Nelson KE (2015). "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" (PDF). Pediatrics. 136 (5): 1008–1017. ISSN 0031-4005. PMID 26504137. doi:10.1542/peds.2015-3108. CS1 maint: Multiple names: authors list (link)
  117. ^ a b c d e Bhatnagar, A.; Whitsel, L.P.; Ribisl, K.M.; Bullen, C.; Chaloupka, F.; Piano, M.R.; Robertson, R.M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "Electronic Cigarettes: A Policy Statement From the American Heart Association". Circulation. 130 (16): 1418–1436. PMID 25156991. doi:10.1161/CIR.0000000000000107. 
  118. ^ "CDC launches powerful new ads in 'Tips From Former Smokers' campaign". Centers for Disease Control and Prevention. 26 March 2015. 
  119. ^ Knight-West, O; Bullen, C (2016). "E-cigarettes for the management of nicotine addiction.". Substance Abuse and Rehabilitation. 7: 111–8. PMC 4993405 . PMID 27574480. doi:10.2147/SAR.S94264. 
  120. ^ Glasser, AM; Collins, L; Pearson, JL; Abudayyeh, H; Niaura, RS; Abrams, DB; Villanti, AC (30 November 2016). "Overview of Electronic Nicotine Delivery Systems: A Systematic Review.". American journal of preventive medicine. PMID 27914771. doi:10.1016/j.amepre.2016.10.036. 
  121. ^ El Dib, R; Suzumura, EA; Akl, EA; Gomaa, H; Agarwal, A; Chang, Y; Prasad, M; Ashoorion, V; Heels-Ansdell, D; Maziak, W; Guyatt, G (23 February 2017). "Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis.". BMJ Open. 7 (2): e012680. PMC 5337697 . PMID 28235965. doi:10.1136/bmjopen-2016-012680. 
  122. ^ a b c Kalkhoran, Sara; Glantz, Stanton A (2016). "E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis". The Lancet Respiratory Medicine. 4: 116–128. PMID 26776875. doi:10.1016/s2213-2600(15)00521-4. 
  123. ^ a b c Rahman, Muhammad Aziz (30 March 2015). "E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis". PLOS ONE. 10: e0122544. PMC 4378973 . PMID 25822251. doi:10.1371/journal.pone.0122544. 
  124. ^ Khoudigian, S; Devji, T; Lytvyn, L; Campbell, K; Hopkins, R; O'Reilly, D (29 January 2016). "The efficacy and short-term effects of electronic cigarettes as a method for smoking cessation: a systematic review and a meta-analysis.". International journal of public health. 61: 257–67. PMID 26825455. doi:10.1007/s00038-016-0786-z. 
  125. ^ Malas, M; van der Tempel, J; Schwartz, R; Minichiello, A; Lightfoot, C; Noormohamed, A; Andrews, J; Zawertailo, L; Ferrence, R (25 April 2016). "Electronic Cigarettes for Smoking Cessation: A Systematic Review.". Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco: ntw119. PMID 27113014. doi:10.1093/ntr/ntw119. 
  126. ^ Orellana-Barrios, MA; Payne, D; Medrano-Juarez, RM; Yang, S; Nugent, K (October 2016). "Electronic Cigarettes for Smoking Cessation.". The American journal of the medical sciences. 352 (4): 420–426. PMID 27776725. doi:10.1016/j.amjms.2016.07.013. 
  127. ^ a b Hartmann-Boyce, Jamie; McRobbie, Hayden; Bullen, Chris; Begh, Rachna; Stead, Lindsay F; Hajek, Peter; Hartmann-Boyce, Jamie (2016). "Electronic cigarettes for smoking cessation". Cochrane Database Syst Rev. 9: CD010216. PMID 27622384. doi:10.1002/14651858.CD010216.pub3. 
  128. ^ a b c d e f Cahn, Z.; Siegel, M. (February 2011). "Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes?". Journal of public health policy. 32 (1): 16–31. PMID 21150942. doi:10.1057/jphp.2010.41. 
  129. ^ Saitta, D.; Ferro, G.A.; Polosa, R. (3 February 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic Advances in Chronic Disease. 5 (2): 6. PMC 3926346 . PMID 24587890. doi:10.1177/2040622314521271. 
  130. ^ Weaver, Michael; Breland, Alison; Spindle, Tory; Eissenberg, Thomas (2014). "Electronic Cigarettes". Journal of Addiction Medicine. 8 (4): 234–240. ISSN 1932-0620. PMC 4123220 . PMID 25089953. doi:10.1097/ADM.0000000000000043. 
  131. ^ Franck, C; Filion, KB; Kimmelman, J; Grad, R; Eisenberg, MJ (17 May 2016). "Ethical considerations of e-cigarette use for tobacco harm reduction.". Respiratory Research. 17 (1): 53. PMC 4869264 . PMID 27184265. doi:10.1186/s12931-016-0370-3. 
  132. ^ a b c Drummond, M.B.; Upson, D (February 2014). "Electronic cigarettes: Potential harms and benefits". Annals of the American Thoracic Society. 11 (2): 236–42. PMID 24575993. doi:10.1513/annalsats.201311-391fr. 
  133. ^ McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 65. Retrieved 20 August 2015. 
  134. ^ a b c d Saitta, D; Ferro, GA; Polosa, R (Mar 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic advances in chronic disease. 5 (2): 50–61. PMC 3926346 . PMID 24587890. doi:10.1177/2040622314521271. 
  135. ^ a b Nowak D, Jörres RA, Rüther T (2014). "E-cigarettes—prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. PMC 4047602 . PMID 24882626. doi:10.3238/arztebl.2014.0349. CS1 maint: Uses authors parameter (link)
  136. ^ "BMA calls for stronger regulation of e-cigarettes" (PDF). British Medical Association. Retrieved 18 November 2013. 
  137. ^ "Principles to Guide AAPHP Tobacco Policy". American Association of Public Health Physicians. Retrieved 31 July 2013. 
  138. ^ a b c Edgar, Julie. "E-Cigarettes: Expert Q&A With the CDC". WebMD. Retrieved 17 November 2013. 
  139. ^ Detailed reference list is located on a separate image page.
  140. ^ Cancer Research UK. "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). cancerresearchuk.org. Retrieved 20 March 2016. 
  141. ^ Odum, L.E.; O'Dell, K.A.; Schepers, J.S. (December 2012). "Electronic cigarettes: do they have a role in smoking cessation?". Journal of pharmacy practice. 25 (6): 611–4. PMID 22797832. doi:10.1177/0897190012451909. 
  142. ^ O'Connor, R.J. (March 2012). "Non-cigarette tobacco products: what have we learnt and where are we headed?". Tobacco control. 21 (2): 181–90. PMC 3716250 . PMID 22345243. doi:10.1136/tobaccocontrol-2011-050281. 
  143. ^ Farsalinos, Konstantinos E; Le Houezec, Jacques (29 September 2015). "Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)". Risk Management and Healthcare Policy. 8: 157–167. PMC 4598199 . PMID 26457058. doi:10.2147/RMHP.S62116. 
  144. ^ Polosa R, Campagna D, Caponnetto P (2015). "What to advise to respiratory patients intending to use electronic cigarettes". Discov Med. 20 (109): 155–61. PMID 26463097. 
  145. ^ Polosa R (2015). "Electronic cigarette use and harm reversal: emerging evidence in the lung". BMC Med. 13: 54. PMC 4365531 . PMID 25857426. doi:10.1186/s12916-015-0298-3. 
  146. ^ "The Potential Adverse Health Consequences of Exposure to Electronic Cigarettes and Electronic Nicotine Delivery Systems". Oncology Nursing Forum. 42 (5): 445–446. 2015. ISSN 0190-535X. PMID 26302273. doi:10.1188/15.ONF.445-446. 
  147. ^ a b c Durmowicz, E.L. (2014). "The impact of electronic cigarettes on the paediatric population". Tobacco Control. 23 (Supplement 2): ii41–ii46. ISSN 0964-4563. PMC 3995262 . PMID 24732163. doi:10.1136/tobaccocontrol-2013-051468. 
  148. ^ a b Bertholon, J.F.; Becquemin, M.H.; Annesi-Maesano, I.; Dautzenberg, B. (2013). "Electronic Cigarettes: A Short Review". Respiration. 86: 433–8. ISSN 1423-0356. PMID 24080743. doi:10.1159/000353253. 
  149. ^ McNeill, A, PH. "Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note". gov.uk. Public Health England. Retrieved 27 May 2016. 
  150. ^ 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. 
  151. ^ Kosmider, Leon; et al. (September 2014). "Carbonyl Compounds in Electronic Cigarette Vapors: Effects of Nicotine Solvent and Battery Output Voltage". Nicotine & Tobacco Research. 16 (10): 1319–1326. ISSN 1462-2203. PMID 24832759. doi:10.1093/ntr/ntu078. 
  152. ^ a b Jerry JM, Collins GB, Streem D (2015). "E-cigarettes: Safe to recommend to patients?". Cleve Clin J Med. 82 (8): 521–6. PMID 26270431. doi:10.3949/ccjm.82a.14054. CS1 maint: Uses authors parameter (link)
  153. ^ "The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014, Chapter 5 - Nicotine" (PDF). Surgeon General of the United States. 2014. pp. 107–138. 
  154. ^ Benowitz, NL; Fraiman, JB (23 March 2017). "Cardiovascular effects of electronic cigarettes.". Nature Reviews Cardiology. PMID 28332500. doi:10.1038/nrcardio.2017.36. 
  155. ^ Pisinger, Charlotta; Døssing, Martin (December 2014). "A systematic review of health effects of electronic cigarettes". Preventive Medicine. 69: 248–260. PMID 25456810. doi:10.1016/j.ypmed.2014.10.009. 
  156. ^ Chang, H. (2014). "Research gaps related to the environmental impacts of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii54–ii58. ISSN 0964-4563. PMC 3995274 . PMID 24732165. doi:10.1136/tobaccocontrol-2013-051480. 
  157. ^ Public Health England. "E-cigarettes in public places and workplaces: a 5-point guide to policy making". uk.gov. Retrieved 7 May 2017. 
  158. ^ Hess, IM; Lachireddy, K; Capon, A (15 April 2016). "A systematic review of the health risks from passive exposure to electronic cigarette vapour.". Public health research & practice. 26 (2). PMID 27734060. doi:10.17061/phrp2621617. 
  159. ^ "State Health Officer's Report on E-Cigarettes: A Community Health Threat" (PDF). California Department of Public Health, California Tobacco Control Program. January 2015. 
  160. ^ Linda J. Vorvick (2013-08-29). "Nicotine and Tobacco". Medline Plus. Retrieved 2015-05-21. 
  161. ^ Palazzolo, Dominic L. (Nov 2013). "Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review.". Frontiers in Public Health. 1 (56). PMC 3859972 . PMID 24350225. doi:10.3389/fpubh.2013.00056. 
  162. ^ a b Schroeder, M.J.; Hoffman, A.C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. ISSN 0964-4563. PMC 3995273 . PMID 24732160. doi:10.1136/tobaccocontrol-2013-051469. 
  163. ^ a b "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. September 2014. Retrieved 15 October 2014. 
  164. ^ Evans, S.E.; Hoffman, A.C. (2014). "Electronic cigarettes: abuse liability, topography and subjective effects". Tobacco Control. 23 (Supplement 2): ii23–ii29. ISSN 0964-4563. PMC 3995256 . PMID 24732159. doi:10.1136/tobaccocontrol-2013-051489. 
  165. ^ Centers for Disease Control and Prevention, (CDC) (6 September 2013). "Notes from the field: electronic cigarette use among middle and high school students – United States, 2011–2012". MMWR. Morbidity and mortality weekly report. 62 (35): 729–30. PMID 24005229. 
  166. ^ "Teens like different forms of tobacco and nicotine". American Cancer Society. Archived from the original on 20 September 2015. Retrieved 18 August 2015. 
  167. ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013. 
  168. ^ Korioth, Trisha. "E-cigarettes easy to buy, can hook kids on nicotine". The American Academy of Pediatrics. Retrieved 17 November 2013. 
  169. ^ "FDA Warns of Health Risks Posed by E-Cigarettes". FDA. 23 July 2009. Retrieved 17 November 2013—Reviewed 17 September 2013 
  170. ^ Goniewicz, Maciej L.; Hajek, Peter; McRobbie, Hayden (2014). "Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications" (PDF). Addiction. 109 (3): 500–507. ISSN 0965-2140. PMID 24345184. doi:10.1111/add.12410. 
  171. ^ Noah Charney (7 December 2014). "America's vaping revolution: How suspicious should we really be of the e-cigarette craze?". Salon magazine. 
  172. ^ "US Patent 3200819. Smokeless non-tobacco cigarette". Retrieved 29 February 2012. 
  173. ^ a b c Mary Bellis (2015). "Who Invented Electronic Cigarettes?". About.com. 
  174. ^ a b P.H. (17 March 2014). "A case of the vapers". The Economist. 
  175. ^ Julie Beck (13 June 2014). "Schrödinger's Cigarette: Is Electronic Safer?". The Atlantic. 
  176. ^ Millstein, Seth (25 April 2009). "The Push to Ban E-Cigarettes: Where's the Proof?". TimeLine. Archived from the original on 2 July 2015. Retrieved 18 February 2016. 
  177. ^ "Electronic Cigarette Sales on the Rise". WalesOnline. 24 August 2011. 
  178. ^ a b c d Sridi, Nicolas (10 July 2013). "I was sure that the electronic cigarette would be welcomed with open arms". Sciences et Avenir. 
  179. ^ "Electronic Atomization Cigarette". Worldwide.espacenet.com. 22 November 2007. 
  180. ^ a b "Dragonite Sells E-Vapor Business To ITG". Convenient Store Decisions. 21 August 2013. 
  181. ^ Tom Hancock (1 October 2013). "China's e-cigarette inventor fights for financial rewards". Fox News Channel. 
  182. ^ a b c d e f g Michael Grothaus (1 October 2014). "Trading addictions: the inside story of the e-cig modding scene". Engadget. 
  183. ^ a b Annabel Denham (10 June 2013). "Brothers who took a punt on a new market". CityAM. Retrieved 4 April 2014. 
  184. ^ a b c d e f g Mike K (9 June 2015). "What Does The Future Hold For Vaping Technology?". Steve K's Vaping World. 
  185. ^ Akam, Simon (27 May 2015). "Big Tobacco fights back: how the cigarette kings bought the vaping industry". Newsweek. Retrieved 22 February 2016. 
  186. ^ "Kodak moment". The Economist. 28 September 2013. Retrieved 11 March 2014. 
  187. ^ a b Mike Esterl (3 February 2014). "Altria Expands in E-Cigarettes With Green Smoke". The Wall Street Journal. Retrieved 7 March 2014. 
  188. ^ Brian Montopoli (11 June 2013). "Tobacco companies bet on electronic cigarettes". CBS News. Retrieved 16 August 2013. 
  189. ^ Sanchez Manning (29 July 2013). "British American Tobacco enters electronic cigarette market in Britain with the 'Vype'". The Independent. 
  190. ^ Gustafsson, Katarina (2 September 2013). "Imperial Tobacco Agrees to Acquire Dragonite's E-Cigarette Unit". Bloomberg. Retrieved 20 November 2013. 
  191. ^ "Lorillard, Inc. Acquires British-based SKYCIG, Expanding its Electronic Cigarette Business". Retrieved 1 October 2013. 
  192. ^ "Lorillard to Rebrand SKYCIG as blu eCigs". Convenience Store News. 27 March 2014. 
  193. ^ a b "Altria Completes Acquisition of Green Smoke". BusinessWire. 1 April 2014. Retrieved 21 November 2014. 
  194. ^ Gideon Spanier (26 June 2014). "Philip Morris buys e-cigarette maker Nicocigs as it warns of falling profits". The Independent. 
  195. ^ a b "Japan Tobacco's Global Ambitions Lead to Logic Acquisition". Convenience Store News. 30 April 2015. 
  196. ^ Mangan, Dan (15 July 2014). "Feeling blu? E-cig company spun off in major tobacco deal". CNBC. 
  197. ^ Koebler, Jason (25 September 2014). "Big Tobacco Has Officially Lost Its Hold on the E-Cigarette Market". Motherboard. Retrieved 25 February 2016. 
  198. ^ a b c d e Couts, Andrew (13 May 2013). "Inside the world of vapers, the subculture that might save smokers' lives". Digital Trends. Retrieved 20 November 2013. 
  199. ^ Park, Andy (26 August 2013). "The Feed: The subculture around e-cigarettes". SBS World News. Retrieved 20 November 2013. 
  200. ^ Barbeau, Amanda M; Burda, Jennifer; Siegel, Michael (2013). "Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach". Addiction Science & Clinical Practice. 8 (1): 5. ISSN 1940-0640. PMC 3599549 . PMID 23497603. doi:10.1186/1940-0640-8-5. 
  201. ^ a b Eric Larson (25 January 2014). "Pimp My Vape: The Rise of E-Cigarette Hackers". Mashable. Retrieved 22 November 2014. 
  202. ^ Molly Osberg (25 February 2014). "CVape life: welcome to the weird world of e-cig evangelists". The Verge. 
  203. ^ a b McKee, M. (2014). "Electronic cigarettes: peering through the smokescreen" (PDF). Postgraduate Medical Journal. 90 (1069): 607–609. ISSN 0032-5473. PMID 25294933. doi:10.1136/postgradmedj-2014-133029. 
  204. ^ a b Jacobs, Emma; Robinson, Duncan (17 April 2014). "E-cigarettes: no smoke without fear". FT Magazine. Retrieved 11 January 2016. 
  205. ^ Tom Gara (14 April 2014). "Are E-Cigarettes Losing Ground in the Vapor Market?". The Wall Street Journal. 
  206. ^ Sottile, Leah (8 October 2014). "The Right to Vape". The Atlantic. Retrieved 28 February 2016. 
  207. ^ Gavin Haynes (22 April 2015). "Daft vapers: the competitive world of e-cigarette smoking". The Guardian. 
  208. ^ Mike Esterl (29 May 2014). "'Vaporizers' Are the New Draw in E-Cigarettes". The Wall Street Journal. 
  209. ^ Staff (13 February 2014). "Generation V E-Cigarettes and Vape Bar aims to convert smokers to e-cigarettes". Daily Nebraskan. 
  210. ^ Neil Nisperos (4 September 2014). "Vaping convention coming to Ontario Convention Center Friday". Inland Valley Daily Bulletin. 
  211. ^ Mary Plass (29 January 2014). "The Cloud Chasers". Vape News Magazine. 
  212. ^ a b c Sean Cooper (23 May 2014). "What you need to know about vaporizers". Engadget. 
  213. ^ Dominique Mosbergen (5 August 2014). "This Man Is An Athlete In The Sport Of 'Cloud Chasing'". The Huffington Post. 
  214. ^ Victoria Bekiempis (1 April 2015). "Veteran E-Cigarette Users Fret 'Cloud Chasers' Give Them a Bad Name". Newsweek. 
  215. ^ Fallon, Claire (19 November 2014). "'Vape' Is Oxford Dictionaries' Word Of The Year". The Huffington Post. 
  216. ^ Etter, J. F.; Bullen, C.; Flouris, A. D.; Laugesen, M.; Eissenberg, T. (May 2011). "Electronic nicotine delivery systems: a research agenda". Tobacco control. 20 (3): 243–8. PMC 3215262 . PMID 21415064. doi:10.1136/tc.2010.042168. 
  217. ^ a b Beard, Emma; Shahab, Lion; Cummings, Damian M.; Michie, Susan; West, Robert (2016). "New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?". CNS Drugs. ISSN 1172-7047. PMID 27421270. doi:10.1007/s40263-016-0362-3. 
  218. ^ Barnaby Page (5 March 2015). "World's law-makers favour basing e-cig rules on tobacco". ECigIntelligence. Tamarind Media Limited. 
  219. ^ Lempert, Lauren K; Grana, Rachel; Glantz, Stanton A (2016). "The importance of product definitions in US e-cigarette laws and regulations". Tobacco Control. 25 (e1): e44–e51. ISSN 0964-4563. PMC 4466213 . PMID 25512432. doi:10.1136/tobaccocontrol-2014-051913. 
  220. ^ a b "U.S. Department of Transportation Explicitly Bans the Use of Electronic Cigarettes on Commercial Flights". March 2, 2016. Retrieved 3 March 2016. 
  221. ^ Sienuic, Kat (29 September 2014). "Public health officers tackle hazy issue of e-cigarettes". The Globe and Mail. 
  222. ^ Kadowaki, Joy; Vuolo, Mike; Kelly, Brian C. (2015). "A review of the current geographic distribution of and debate surrounding electronic cigarette clean air regulations in the United States". Health & Place. 31: 75–82. ISSN 1353-8292. PMC 4305454 . PMID 25463920. doi:10.1016/j.healthplace.2014.11.003. 
  223. ^ "E-cigarettes to be stubbed out for under-18s". BBC News. 26 January 2014. 
  224. ^ a b c "The Facts on the FDA's New Tobacco Rule". US Department of Health and Human Services. US Food and Drug Administration. 7 August 2016. 
  225. ^ "Retailer Overview of FDA Regulations for Selling Tobacco Products". US Department of Health and Human Services. US Food and Drug Administration. 8 August 2016. 
  226. ^ Eric Lipton (2 September 2016). "A Lobbyist Wrote the Bill. Will the Tobacco Industry Win Its E-Cigarette Fight?". The New York Times. 
  227. ^ Gray, Eliza (27 February 2014). "Europe Sets New Rules for E-Cigs While the U.S. Drags Its Feet". Time (magazine). 
  228. ^ "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. US Food and Drug Administration. 79 (80): 23142–23207. 25 April 2014. 
  229. ^ Sabrina Tavernise (24 April 2014). "F.D.A. Will Propose New Regulations for E-Cigarettes". The New York Times. 
  230. ^ National Conference of State Legislatures (5 May 2016). "Alternative Nicotine Products Electronic Cigarettes". National Conference of State Legislatures. 
  231. ^ Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (01): 060–065. ISSN 0094-6176. PMID 24343348. doi:10.1055/s-0033-1363468. 
  232. ^ Maloney, Erin K.; Cappella, Joseph N. (2015). "Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers?". Health Communication. 31: 1–10. ISSN 1041-0236. PMID 25758192. doi:10.1080/10410236.2014.993496.
Ends Electronic Cigarette

E-cigarette seller destroys €135,000 worth of nicotine liquid - Nicorex! NB - OPEN SUBTITLES!

 UK

The entering into force of the requirements of the European tobacco products directive in Estonia made e-cigarette seller Nicorex Baltic destroy 19,000 bottles of e-cigarette liquid worth €135 000, as the packaging size did not meet the new requirements.

The liquids were actually in order, had undergone laboratory testing and met the new requirements, but their packaging did not have the necessary warnings on them and the boxes did not contain instructions.

Nicorex said that the transition period allowed by the government was too short, as the shelf life of the liquids was two years, but the length of the transition period only one year.

At the same time, Nicorex welcomed the requirement that the liquids have to undergo laboratory testing and that both the equipment and liquids must be registered in a single European database.

Nicorex described the restrictions concerning the size of packaging as unreasonable, as they increased the ecological footprint.

The transition period under the new tobacco law arising from the European tobacco products directive will end on May 20, after which the stricter requirements will apply to e-cigarettes in full.

Liquids can't be sold in containers bigger than 10 ml, they can't contain more nicotine than 20 milligrams per milliliter, and the vaporizer can't be bigger than 2 ml.

The packaging needs to include a leaflet, instructions, a batch number, a date, and a warning that nicotine is an addictive substance.


 

Uk E Liquid Free Delivery UK

Uk Vape Brands UK

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.

E Cigarette Electronic Cigarette

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 appeals.

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.

5%.

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.

No worries.

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.

V.

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.

Green Smoke.

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.

00.

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.

Okay.

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.

Male/female.

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.

I'm ________.

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.

P_______.

Okay.

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.

KM: 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.

Dr.

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.

Not much.

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.

Dr.

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.

None.

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.

A Dr.

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.

V.

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.

Okay.

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 not.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

So, ah, first of all we can build a little bit.

We've been researching cigarettes for more than 40 years.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

Thank you.

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.

Yeah.

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.

S.

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.

Okay.

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.

Okay.

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.

All right.

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.

Yes.

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.

Okay.

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.

All right.

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.

Electronic Cigarette Buy

Electronic cigarette aerosol and e-liquid

 UK

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 appeals.

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.

5%.

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.

No worries.

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.

V.

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.

Green Smoke.

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.

00.

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.

Okay.

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.

Male/female.

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.

I'm ________.

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.

P_______.

Okay.

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.

KM: 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.

Dr.

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.

Not much.

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.

Dr.

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.

None.

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.

A Dr.

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.

V.

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.

Okay.

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 not.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

So, ah, first of all we can build a little bit.

We've been researching cigarettes for more than 40 years.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

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.

Okay.

Thank you.

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.

Yeah.

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.

S.

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.

Okay.

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.

Okay.

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.

All right.

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.

Yes.

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.

Okay.

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.

All right.

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.


 

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