E-cigs vs. T-cigs
Electronic cigarettes may be less harmful in the UK than cigarettes but may still be dangerous. Under which circumstances should a person use ecigs? Will they fill your body with plastic?
Electronic cigarettes can contain propylene glycol or vegetable glycerine with nicotine (and in at least two cases polyethylene glycol 400) to form a solution that when heated by an atomizer, produces a visible vapour that provides nicotine to the bloodstream via the lungs when inhaled.
Electronic cigarettes have not been studied enough by scientists in laboratories to form conclusive evidence that their use is either beneficial or harmful to humans. However, some are concerned that unknown side-effects could occur with continuous, consistent use of electronic cigarettes, including cancer.
Behaviour surrounding their use is worrisome because e-cigs are being used habitually by a percentage of non-smokers who otherwise would not use nicotine, they may seem attractive to children, they are not closely regulated, and their use makes it very easy to overdose on nicotine even for experienced smokers.
UK Electronic Cigarettes and E-LiquidVarious types of e-cigarettes.
Electronic cigarettes or e-cigarettes[note 1] are handheld electronic devices that try to create a feeling like smoking tobacco. They work by heating a liquid to generate an aerosol, commonly called a "vapor", that the user inhales. Using e-cigarettes is sometimes called vaping. The liquid in the e-cigarette, called e-liquid, is usually made of nicotine, propylene glycol, glycerine, and flavorings. Not all e-liquids contain nicotine.
The health risks of e-cigarettes are uncertain. They are likely safer than tobacco cigarettes, but the long-term health effects are not known. They can help some smokers quit. When used by non-smokers, e-cigarettes can lead to nicotine addiction, and there is concern that children could start smoking after using e-cigarettes. According to some US sources, minors who use e-cigarettes are more likely to smoke later in life. Public Health England attributes this link to a liability for the use of both products rather than one resulting in the other. So far, no serious adverse effects have been reported in trials. Less serious adverse effects include throat and mouth irritation, vomiting, nausea, and coughing.
E-cigarettes create an aerosol, commonly called vapor, generally containing nicotine, flavors, glycerol and propylene glycol. Its exact composition varies. The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette aerosol. Those present are mostly below 1% corresponding levels in tobacco smoke. The aerosol can contain toxicants and traces of heavy metals at levels permissible in inhalation medicines, and potentially harmful chemicals not found in tobacco smoke at concentrations permissible by workplace safety standards. However, chemical concentrations may exceed the stricter public safety limits.
The modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, and as of 2015 most e-cigarettes are made in China. Since they were first sold in 2004 their global use has risen exponentially. In the United States and the United Kingdom their use is widespread, and some US schoolchildren use them. Reasons for using e-cigarettes involve trying to quit smoking, reduce risk, or save money, though many use them recreationally. A majority of users still smoke tobacco, causing concerns that dual use may "delay or deter quitting". About 60% of UK users are smokers and roughly 40% are ex-smokers, while use among never-smokers is "negligible". Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is debated in many countries. A European directive in 2016, set limits for liquids and vaporizers, ingredients, and child-proof liquid containers. As of August 2016, the US FDA extended its regulatory power to include e-cigarettes. There are around 500 brands of e-cigarette with global sales in excess of US$7 billion.
Electronic cigarettes are also known as e-cigarettes, e-cigs, EC, electronic nicotine delivery systems (ENDS) or electronic non-nicotine delivery systems (ENNDS), personal vaporizers, or PVs. They are handheld devices, often made to look like conventional cigarettes, and used in a similar way. E-liquid or juice are names for the flavored solution that goes inside the e-cigarette. An aerosol, or vapor, is produced by heating the e-liquid. Irish public health discussions refer to NMNDS ("non-medicinal nicotine delivery systems").Aerosol (vapor) exhaled by an e-cigarette user.
Since their introduction to the market in 2004, global usage of e-cigarettes has risen exponentially. By 2013, there were several million users globally. Awareness and use of e-cigarettes greatly increased in a relatively short period of time. However, growth in the US and UK had reportedly slowed in 2015, lowering market forecasts for 2016.
Most users have a history of smoking regular cigarettes. At least 52% of smokers or ex-smokers have vaped. Of smokers who have, less than 15% became everyday e-cigarette users. Though e-cigarette use among those who have never smoked is very low, it continues to rise. A survey of e-cigarette users conducted from 2011–2012 found that only 1% of respondents used liquid without nicotine.
Everyday use is common among e-cigarette users. Vapers mostly keep smoking, although many say vaping helps them cut down or quit smoking. Most e-cigarette users are middle-aged men who also smoke traditional cigarettes, either to help them quit or for recreational use. E-cigarette use was also rising among women as of 2014. Some young people who have tried an e-cigarette have never smoked tobacco, so ECs can be a starting point for nicotine use. On the other hand, Public Health England found no evidence e-cigarettes increase teen tobacco smoking. They noted tentative evidence that e-cigarettes divert youth away from cigarettes. A 2014 review raised ethical concerns about minors' e-cigarette use and the potential to weaken cigarette smoking reduction efforts.
In the US, as of 2014, 12.6% of adults had used an e-cigarette at least once and approximately 3.7% were still using them. 1.1% of adults were daily users. Non-smokers and former smokers who had quit more than four years earlier were extremely unlikely to be current users. Former smokers who had recently quit were more than four times as likely to be daily users as current smokers. Experimentation was more common among younger adults, but daily users were more likely to be older adults.Play media National Institute on Drug Abuse director Nora Volkow discussing a study that shows teens using e-cigarettes are more likely to start smoking tobacco.
The recent decline in smoking has accompanied a rapid growth in the use of alternative nicotine products among young people and young adults. In the US, vaping among young people exceeded smoking in 2014. As of 2014, up to 13% of American high school students have used them. Between 2013 and 2014, vaping among students tripled. In 2013 the Centers for Disease Control and Prevention (CDC) estimated that around 160,000 students between 2011 and 2012 who had tried vaping had never smoked. E-cigarette use among never-smoking youth in the US correlates with elevated desires to use traditional cigarettes. Teenagers who had used an e-cigarette were more inclined to become smokers than those who had not. In the 2015 Monitoring the Future survey, a majority of students who used electronic cigarettes reported using liquid without nicotine the last time they vaped. The majority of young people who vape also smoke. A 2010–2011 survey of students at two US high schools found that vapers were more likely to use hookah and blunts than smokers. Among grade 6 to 12 students in the US, the proportion who have tried them rose from 3.3% in 2011 to 6.8% in 2012. Those still vaping over the last month rose from 1.1% to 2.1% and dual use rose from 0.8% to 1.6%. Over the same period, the proportion of grade-6-to-12 students who regularly smoke tobacco fell from 7.5% to 6.7%.
In the UK, user numbers have increased from 700,000 in 2012 to 2.6 million in 2015, but use by current smokers remained flat at 17.6% from 2014 into 2015 (in 2010, it was 2.7%). About one in 20 adults in the UK uses e-cigarettes. In the UK in 2015, 18% of regular smokers said they used e-cigarettes and 59% said they had used them in the past. Among those who had never smoked, 1.1% said they had tried them and 0.2% still use them. In 2013, among those under 18, 7% have used e-cigarettes at least once. Among non-smokers' children, 1% reported having tried e-cigarettes "once or twice", and there was no evidence of continued use. About 60% of all users are smokers and most of the rest are ex-smokers, with "negligible" numbers of never-smokers. In 2015 figures showed around 2% monthly EC-usage among under-18s, and 0.5% weekly, and despite experimentation, "nearly all those using EC regularly were cigarette smokers". 10–11-year-old Welsh never-smokers are more likely to use e-cigarettes if a parent used e-cigarettes.
In France in 2014, between 7.7 and 9.2 million people have tried e-cigarettes and 1.1 to 1.9 million use them on a daily basis. 67% of French smokers use e-cigarettes to reduce or quit smoking. Of French people who have tried e-cigarettes, 9% have never smoked tobacco. Of the 1.2% who had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited e-cigarettes as essential in quitting.
The frequency of vaping in youth is low. Minors who use one tobacco product such as e-cigarettes are more likely to later use other tobacco products such as cigarettes, which likely arises from a common liability for the use of both products. Young people who vape but do not smoke are more likely to try smoking than their peers who do not vape.E-cigarettes often have a high-tech look. Candy, fruit and coffee flavored e-liquid.
Reasons for e-cigarette use often relate to quitting smoking and recreation. Many users believe vaping is healthier than smoking, although some are concerned about possible adverse health effects. Some use them to circumvent smoke-free laws and policies, or to cut back on cigarette smoking. 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking. In the same survey, 26% of respondents would use them in areas where smoking was banned. Not having odor from smoke on clothes on some occasions prompted interest in or use of e-cigarettes. Many e-cigarette users use them because they believe they are safer than conventional cigarettes.
Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one. College students often vape for experimentation. Expensive marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use". Exposure to e-cigarette advertising influenced people to try them.
Some researchers are concerned about vaping during pregnancy. E-cigarettes feel or taste similar to traditional cigarettes, and vapers disagreed about whether this was a benefit or a drawback. The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.
Some users stopped vaping due to issues with the devices. Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use. Some surveys found that a small percentage of users' motives were to avoid smoking bans, but other surveys found that over 40% of users said they used the device for this reason.
The health and lifestyle appeal may also encourage young non-smokers to use e-cigarettes, as they may perceive that trying e-cigarettes is less risky and more socially appealing. This may decrease negative beliefs or concerns about nicotine addiction. Marketing might appeal to young people as well as adults. Adolescent experimenting with e-cigarettes may be sensation seeking behavior, and is not likely to be associated with tobacco reduction or quitting smoking. Young people may view e-cigarettes as a symbol of rebellion. The main reasons young people experimented with e-cigarettes were due to curiosity, flavors, and peer influences. The National Association of County and City Health Officials say there is concern that e-cigarettes may appeal to youth because of their high-tech design, assortment of flavors, and accessibility online. The Heart and Stroke Foundation claims that candy and fruit flavored e-cigarettes are designed to appeal to young people. Infants and toddlers could ingest the e-liquid from an e-cigarette device out of curiosity.
Users may begin by trying a disposable e-cigarette. Users often start with e-cigarettes resembling normal cigarettes, eventually moving to a later-generation device. Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit", and users may adjust their devices to provide more vapor for better "throat hits".Special e-liquid mixes with THC or other cannabinoids are sold.
The emergence of e-cigs has given cannabis smokers a new method of inhaling cannabinoids. E-cigs differ from traditional marijuana cigarettes in several respects. It is assumed that vaporizing cannabinoids at lower temperatures is safer because it produces smaller amounts of toxic substances than the hot combustion of a marijuana cigarette. Recreational cannabis users can discreetly "vape" deodorized cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as "stealth vaping". While cannabis is not readily soluble in the liquid used for e-cigs, recipes containing synthetic cannabinoids which are soluble may be found on the Internet.
E-cigarettes may be used with other substances and cartridges can potentially be filled with e-liquid containing substances other than nicotine, thus serving as a new and potentially dangerous way to deliver other psychoactive drugs, for example THC.
Cannabinoid-enriched e-liquids require lengthy, complex processing. Some are available on the Internet despite lack of quality control, expiry date, conditions of preservation, or any toxicological and clinical assessment. The health consequences of vaping cannabis preparations are largely unknown.Exploded view of electronic cigarette with transparent clearomizer and changeable dual-coil head. This model allows for a wide range of settings. Electronic cigarettes can come in very different forms—such as this hand-grenade-shaped variant.
The main components of an e-cigarette are a mouthpiece, a cartridge (tank), a heating element/atomizer, a microprocessor, a battery, and possibly a LED light on the end. The only exception to this are mechanical e-cigarettes (mods) which contain no electronics; the circuit is closed by a mechanical action switch. An atomizer comprises a small heating element, or coil, that vaporizes e-liquid and wicking material that draws liquid onto the coil. When the user pushes a button, or (in some variations) activates a pressure sensor by inhaling, the heating element atomizes the liquid solution. The e-liquid reaches a temperature of roughly 100-250 °C within a chamber to create an aerosolized vapor, which the user then inhales, rather than cigarette smoke. The aerosol provides a flavor and feel similar to tobacco smoking.
There are three main types of e-cigarettes: cigalikes, looking like cigarettes; eGos, bigger than cigalikes with refillable liquid tanks; and mods, assembled from basic parts or by altering existing products. As the e-cigarette industry continues to evolve, new products are quickly developed and brought to market. First generation e-cigarettes tend to look like tobacco cigarettes and so are called "cigalikes". Most cigalikes look like cigarettes but there is some variation in size. A traditional cigarette is smooth and light while a cigalike is rigid and slightly heavier. Second generation devices are larger overall and look less like tobacco cigarettes. Third generation devices include mechanical mods and variable voltage devices. The fourth generation includes Sub ohm tanks and temperature control devices. The power source is the biggest component of an e-cigarette, which is frequently a rechargeable lithium-ion battery.
E-liquid is the mixture used in vapor products such as e-cigarettes and generally consists of propylene glycol, glycerin, water, nicotine, and flavorings. While the ingredients vary the liquid typically contains 95% propylene glycol and glycerin. There are many e-liquids manufacturers in the USA and worldwide, and upwards of 8,000 flavors. While there are currently no US Food and Drug Administration (FDA) manufacturing standards for e-liquid, the FDA has proposed regulations that were expected to be finalized in late 2015.[needs update] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).Main article: Positions of medical organizations on electronic cigarettes 2014 Centers for Disease Control (CDC) press release about e-cigarettes.
Medical organizations differ about the health implications of vaping. Many medical organizations have made statements about their health and safety. There is general agreement that e-cigarettes expose users to fewer toxicants than tobacco. International organizations have hesitated to recommend e-cigarettes for quitting smoking, because of limited evidence of effectiveness and safety. Some from the UK have recommended their use by smokers unwilling or unable to quit.
In August 2016, a World Health Organization (WHO) report found "there is not enough research to quantify the relative risk of ENDS/ENNDS over combustible products. Therefore, no specific figure about how much 'safer' the use of these products is compared to smoking can be given any scientific credibility at this time." In July 2014, a WHO report found limited evidence that e-cigarettes may help some smokers quit, but did not reach conclusions. Smokers should be encouraged to use approved methods for help with quitting, although e-cigarettes may have a role in helping those who have failed to quit by other means. Smokers will get the maximum health benefit if they completely quit all nicotine use. A policy briefing by the Framework Convention Alliance notes widespread agreement that e-cigarettes are "almost certainly considerably less hazardous for individuals than cigarettes", but also notes widespread disagreement on the likelihood and impact of dual use, uptake by never-smokers, and re-normalisation of smoking. The World Lung Foundation has applauded the WHO report's recommendation of tighter regulation due to safety concerns and the risk of increased nicotine addiction or tobacco use among young people.
In a 2015 joint statement, Public Health England and twelve other UK medical bodies concluded "e-cigarettes are significantly less harmful than smoking". PHE also stated that e-cigarettes are estimated to be 95% less harmful than smoking. The UK National Health Service believes that e-cigarettes have about 5% of the risk of tobacco cigarettes, but also feels there will not be a complete understanding of their safety for many years. There are clinical trials in progress to test the quality, safety and effectiveness of e-cigarettes, but until these are complete the NHS maintains that the government could not give any advice on them or to recommend their use. In 2016, the Royal College of Physicians called to "promote e-cigarettes widely as substitute for smoking", concluding that "e-cigarettes are likely to be beneficial to UK public health".The United States Centers for Disease Control and Prevention released a 2016 report titled E-cigarette Ads and Youth which concerned marketing towards adolescents.
In 2016, the FDA stated its position that e-cigarettes are "likely less hazardous for an individual user than continued smoking of traditional cigarettes", but that the net population effect is unknown. In 2015, the United States Preventive Services Task Force concluded there is insufficient evidence to recommend e-cigarettes for smoking cessation, and recommended clinicians instead recommend more proven smoking cessation aids. The National Institute on Drug Abuse raises concern over the possibility that they could perpetuate nicotine addiction and thus interfere with quitting. In 2015, the American Academy of Pediatrics strongly recommended against using e-cigarettes to quit smoking, stating that for adolescents e-cigarettes are not effective in treating tobacco dependence. In August 2014, the American Heart Association released a policy statement concluding that while e-cigarette aerosol is much less toxic then cigarette smoke, there is insufficient evidence for clinicians to counsel smokers to use them as a primary cessation aid. If a patient failed initial treatment or refuses to use cessation medication, and wishes to use e-cigarettes to quit, it is reasonable to support the attempt after informing about the uncertainties. In 2014, the US FDA said "E-cigarettes have not been fully studied, so consumers currently don't know: the potential risks of e-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products. Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death."Play media CDC launches "Tips From Former Smokers" ad campaign in 2015. The main information on e-cigarettes begins at 24:45.
The available research on e-cigarette use for smoking cessation is limited to three randomized controlled trials and some user surveys, case reports, and cohort studies. Some consider the evidence contradictory, while others attribute negative outcomes to inappropriate study design. Some medical authorities recommend that e-cigarettes have a role in smoking cessation, and others disagree. On the one hand, Public Health England recommends that stop-smoking practitioners should (1) advise people who want to quit to try e-cigarettes if they are failing with conventional nicotine replacement therapy (NRT); and (2) advise people who cannot or do not want to quit to switch to e-cigarettes. On the other hand, the United States Preventive Services Task Force advised only use of conventional NRT products in smoking cessation and found insufficient evidence to recommend e-cigarettes for this purpose.
There is tentative evidence that they can help people quit smoking, but studies pertaining to their potential impact on smoking cessation and reduction is very limited. However, a 2016 meta-analysis based on 20 different studies found that smokers who used electronic cigarettes were 28% less likely to quit than those who had not tried electronic cigarettes. This finding persisted whether the smokers were initially interested in quitting or not. A 2015 meta-analysis on clinical trials found that nicotine-containing e-liquids are more effective than nicotine-free ones for quitting smoking. They compared their finding that nicotine-containing e-cigarettes helped 20% of people quit with the results from other studies that found conventional NRT helps 10% of people quit. There has only been one study directly comparing first generation e-cigarettes to conventional NRT as smoking cessation tools, so the comparative effectiveness is not known. Two 2016 reviews found a trend towards benefit of e-cigarettes with nicotine for smoking cessation, but that the evidence was of low quality. Another 2016 review found that the combined abstinence rate among smokers using e-cigarettes in prospective studies was 29.1%. The same review noted that few clinical trials had yet been conducted on their effectiveness, and only one had included a group using other cessation methods.
However, e-cigarettes have not been subject to the same efficacy testing as nicotine replacement products. Several authorities, including the World Health Organisation, take the view that there is not enough evidence to recommend e-cigarettes for quitting smoking in adults, and there are studies showing a decline in smoking cessation among dual users. A 2014 review found that e-cigarettes do not seem to improve cessation rates compared to regulated nicotine replacement products, and a trial found 29% of e-cigarette users were still vaping at 6 months, but only 8% of patch users still wore patches at 6 months. There is low-quality evidence that vaping assists smokers to quit smoking in the long-term compared with nicotine-free vaping. Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine. E-cigarettes without nicotine may reduce tobacco cravings because of the smoking-related physical stimuli.
Tobacco harm reduction (THR) is replacing tobacco cigarettes with lower risk products to reduce death and disease. THR has been controversial out of fear that tobacco companies cannot be trusted to make products that will reduce this risk. E-cigarettes can reduce smokers' exposure to carcinogens and other toxic substances found in tobacco.
Tobacco smoke contains 100 known carcinogens, and 900 potentially cancer causing chemicals, none of which has been found in more than trace quantities in e-cigarette vapor. While e-cigarettes cannot be considered "safe" because there is no safe level for carcinogens, they are doubtless safer than tobacco cigarettes. E-cigarettes are not dangerous enough to warrant serious public health concerns given the known risks of conventional cigarettes. The same review concluded that evidence supported "the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking", provided efforts were also made to protect vulnerable groups from e-cigarettes.
A core concern is that smokers who could have quit completely will develop an alternative nicotine addiction instead. A 2014 review stated that promotion of vaping as a harm reduction aid is premature, but they could help to lower tobacco-related death and disease if examined more thoroughly. Another review found that compared with cigarettes, e-cigarettes are likely to be much less, if at all, harmful to users or bystanders. The authors warned against the potential harm of excessive regulation and advised health professionals to consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking. A 2015 Public Health England report concluded that e-cigarette use "releases negligible levels of nicotine into ambient air with no identified health risks to bystanders". A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction. A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions. E-cigarette use for risk reduction in high-risk groups such as people with mental disorders is unavailable.
Hazards associated with products currently on the market are probably low, and certainly much lower than smoking. However, harms could be reduced further through appropriate product standards. Many smokers want to reduce harm from smoking by using these products. The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking. The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and smokeless tobacco for long term use instead of smoking. In an interview, the director of the Office on Smoking and Health for the U.S. federal agency Centers for Disease Control and Prevention (CDC) believes that there is enough evidence to say that using e-cigarettes is likely less harmful than smoking a pack of conventional cigarettes. However, due to the lack of regulation of the contents of e-cigarettes and the presence of nicotine, the CDC has issued warnings. A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both. This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."Main articles: Safety of electronic cigarettes and Electronic cigarette aerosol and e-liquid Adverse effects of vaping.
The safety of electronic cigarettes is uncertain. However, they are likely substantially safer than tobacco cigarettes. There is considerable variation between vaporizers and in quality of their liquid ingredients and thus the contents of the vapor. Reviews on the safety of electronic cigarettes, analyzing almost the same studies, resulted in substantially different conclusions. In July 2014 the World Health Organization (WHO) report cautioned about potential risks of using e-cigarettes. Regulated US Food and Drug Administration (FDA) products such as nicotine inhalers are probably safer than e-cigarettes. In 2015, Public Health England stated that e-cigarettes are estimated to be 95% less harmful than smoking. A 2014 systematic review concluded that the risks of e-cigarettes have been exaggerated by health authorities and stated that while there may be some remaining risk, the risk of e-cigarette use is likely small compared to smoking tobacco.
The long-term effects of e-cigarette use are unknown. Improvements in lung function and pulmonary health have been demonstrated among smokers who have switched to e-cigarettes. A 2014 Cochrane review found no serious adverse effects reported in clinical trials. Less serious adverse effects from e-cigarette use include throat and mouth irritation, vomiting, nausea, and cough. The evidence suggests they produce less harmful effects than tobacco. A 2014 WHO report said, "ENDS use poses serious threats to adolescents and fetuses." Aside from toxicity, there are also risks from misuse or accidents such as contact with liquid nicotine, fires caused by vaporizer malfunction, and explosions as result from extended charging, unsuitable chargers, or design flaws. Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns. There is a small risk of battery explosion in devices modified to increase battery power.
The e-liquid has a low level of toxicity, but contamination with various chemicals has been found. The majority of toxic chemicals found in tobacco smoke are absent in e-cigarette vapor. Those which are present are mostly below 1% of the corresponding levels in tobacco smoke, and far below safety limits for occupational exposure. Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metals. Normal usage of e-cigarettes generates very low levels of formaldehyde. A 2015 review found that later-generation e-cigarettes set at higher power may generate equal or higher levels of formaldehyde compared to smoking. A 2015 review found that these levels were the result of overheating under test conditions that bear little resemblance to common usage. The 2015 Public Health England report looking at the research concluded that by applying maximum power and increasing the time the device is used on a puffing machine, e-liquids can thermally degrade and produce high levels of formaldehyde. Users detect the "dry puff" and avoid it, and the report concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes." E-cigarette users who use e-cigarettes that contain nicotine are exposed to its potentially harmful effects. Nicotine is associated with cardiovascular disease, potential birth defects, and poisoning.In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo. There is inadequate research to demonstrate that nicotine is associated with cancer in humans. The risk is probably low from the inhalation of propylene glycol and glycerin. No information is available on the long-term effects of the inhalation of flavors. Most of the cardiovascular effects of ECs are consistent with those of nicotine. According to a 2017 review, it is possible that ECs may have adverse cardiovascular effects on users, especially those who already have cardiovascular disease. However, this review also concluded that "the risk is thought to be less than that of cigarette smoking based on qualitative and quantitative comparisons of EC aerosol versus cigarette smoke constituents."
E-cigarettes create vapor that consists of ultrafine particles, with the majority of particles in the ultrafine range. The vapor has been found to contain flavors, propylene glycol, glycerin, nicotine, tiny amounts of toxicants, carcinogens, heavy metals, and metal nanoparticles, and other chemicals. Exactly what comprises the vapor varies in composition and concentration across and within manufacturers. However, e-cigarettes cannot be regarded as simply harmless. There is a concern that some of the mainstream vapor exhaled by e-cigarette users can be inhaled by bystanders, particularly indoors. E-cigarette use by a parent might lead to inadvertent health risks to offspring. A 2014 review recommended that e-cigarettes should be regulated for consumer safety. There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges. A 2014 review found "disposable e-cigarettes might cause an electrical waste problem."
The World Health Organization has concluded regarding second hand aerosol (SHA) "that while there are a limited number of studies in this area, it can be concluded that SHA is a new air contamination source for particulate matter, which includes fine and ultrafine particles, as well as 1,2-propanediol, some VOCs [volatile organic compounds], some heavy metals, and nicotine" and "[i]t is nevertheless reasonable to assume that the increased concentration of toxicants from SHA over background levels poses an increased risk for the health of all bystanders". Public Health England has concluded that "international peer-reviewed evidence indicates that the risk to the health of bystanders from secondhand e-cigarette vapour is extremely low and insufficient to justify prohibiting e-cigarettes". A systematic review concluded, "the absolute impact from passive exposure to EC [electronic cigarette] vapour has the potential to lead to adverse health effects. The risk from being passively exposed to EC vapour is likely to be less than the risk from passive exposure to conventional cigarette smoke."
Nicotine, a key ingredient in e-liquids, is a highly addictive substance, on a level comparable to heroin and cocaine. Nicotine stimulates regions of the cortex associated with reward, pleasure and reducing anxiety. When nicotine intake stops, withdrawal symptoms include cravings for nicotine, anger/irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger or weight gain, and difficulty concentrating. It is not clear whether e-cigarette use will decrease or increase overall nicotine addiction, but the nicotine content in e-cigarettes is adequate to sustain nicotine dependence.
The World Health Organization is concerned about addiction for non-smokers, and the National Institute on Drug Abuse said e-cigarettes could maintain nicotine addiction in those who are attempting to quit. The limited available data suggests that the likelihood of abuse from e-cigarettes is smaller than traditional cigarettes. A 2014 systematic review found that the concerns that e-cigarettes could lead non-smokers to start smoking are unsubstantiated. No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction, but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.
Many studies have focused on young people, since youthful experimentation with e-cigarettes could lead to lifelong addiction. Various organizations, including the UATLD, the AAP and the FDA, have expressed concern that e-cigarette use could increase nicotine addiction in youth. Although regular use of e-cigarettes is generally very low by people who have never smoked, significant numbers of teenagers who have never smoked tobacco have experimented with e-cigarettes. The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown, as is the extent to which e-cigarette use could lead to addiction or substance dependence in youth.
Smoking a traditional cigarette yields between 0.5 and 1.5 mg of nicotine, but the nicotine content of the cigarette is only weakly correlated with the levels of nicotine in the smoker's bloodstream. The amount of nicotine in the e-cigarette aerosol varies widely either from puff-to-puff or among products of the same company. In practice e-cigarette users tend to reach lower blood nicotine concentrations than smokers, particularly when the users are inexperienced or using earlier-generation devices. Nicotine in tobacco smoke is absorbed into the bloodstream rapidly, and e-cigarette vapor is relatively slow in this regard. The concentration of nicotine in e-liquid ranges up to 36 mg/mL. New EU regulations cap this at a maximum of 2% (20 mg/mL), but this is an arbitrary ceiling based on limited data. In practice the nicotine concentration in an e-liquid is not a reliable guide to the amount of nicotine that reaches the bloodstream.
The earliest e-cigarette can be traced to American Herbert A. Gilbert, who in 1963 patented "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device produced flavored steam without nicotine. The patent was granted in 1965. Gilbert's invention was ahead of its time. There were prototypes, but it received little attention and was never commercialized because smoking was still fashionable at that time. Gilbert said in 2013 that today's electric cigarettes follow the basic design set forth in his original patent.
Hon Lik, a Chinese pharmacist and inventor who worked as a research pharmacist for a company producing ginseng products, is credited with the invention of the modern e-cigarette. Lik quit smoking after his father, also a heavy smoker, died of lung cancer. In 2001, he thought of using a high frequency, piezoelectric ultrasound-emitting element to vaporize a pressurized jet of liquid containing nicotine. This design creates a smoke-like vapor. Lik said that using resistance heating obtained better results and the difficulty was to scale down the device to a small enough size. Lik's invention was intended to be an alternative to smoking.The Ruyan e-cigar was first launched in China in 2004.
Hon Lik registered a patent for the modern e-cigarette design in 2003. The e-cigarette was first introduced to the Chinese domestic market in 2004. Many versions made their way to the U.S., sold mostly over the Internet by small marketing firms. E-cigarettes entered the European market and the US market in 2006 and 2007. The company that Lik worked for, Golden Dragon Holdings, registered an international patent in November 2007. The company changed its name to Ruyan (如烟, literally "Resembling smoking") later the same month and started exporting its products. Many US and Chinese e-cig makers copied his designs illegally, so Lik has not received much financial reward for his invention (although some US manufacturers have compensated him through out of court settlements). Ruyan later changed its company name to Dragonite International Limited. Most e-cigarettes today use a battery-powered heating element rather than the earlier ultrasonic technology design.
When e-cigarettes entered the international market, some users were dissatisfied with their performance, and the e-cigarette continued to evolve from the first generation three-part device. In 2007 British entrepreneurs Umer and Tariq Sheikh invented the cartomizer. This is a mechanism that integrates the heating coil into the liquid chamber. They launched this new device in the UK in 2008 under their Gamucci brand, and the design is now widely adopted by most "cigalike" brands. Other users tinkered with various parts to produce more satisfactory homemade devices, and the hobby of "modding" was born. The first mod to replace the e-cigarette's case to accommodate a longer-lasting battery, dubbed the "screwdriver", was developed by Ted and Matt Rogers in 2008. Other enthusiasts built their own mods to improve functionality or aesthetics. When pictures of mods appeared at online vaping forums many people wanted them, so some mod makers produced more for sale.
The demand for customizable e-cigarettes prompted some manufacturers to produce devices with interchangeable components that could be selected by the user. In 2009, Joyetech developed the eGo series which offered the power of the screwdriver model and a user-activated switch to a wide market. The clearomizer was invented in 2009. Originating from the cartomizer design, it contained the wicking material, an e-liquid chamber, and an atomizer coil within a single clear component. The clearomizer allows the user to monitor the liquid level in the device. Soon after the clearomizer reached the market, replaceable atomizer coils and variable voltage batteries were introduced. Clearomizers and eGo batteries became the best-selling customizable e-cigarette components in early 2012.
International tobacco companies dismissed e-cigarettes as a fad at first. However, recognizing the development of a potential new market sector that could render traditional tobacco products obsolete, they began to produce and market their own brands of e-cigarettes and acquire existing e-cigarette companies.blu eCigs, a prominent US e-cigarette manufacturer, was acquired by Lorillard Inc. in 2012.British American Tobacco was the first tobacco business to sell e-cigarettes in the UK. They launched Vype in 2013, while Imperial Tobacco's Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite International Limited for $US 75 million in 2013 and launched Puritane in partnership with Boots UK. On 1 October 2013 Lorillard Inc. acquired another e-cigarette company, this time the UK based company SKYCIG. SKY was rebranded as blu. On 3 February 2014, Altria Group, Inc. acquired popular electronic cigarette brand Green Smoke for $110 million. The deal was finalized in April 2014 for $110 million with $20 million in incentive payments. Altria also markets its own e-cigarette, the MarkTen, while Reynolds American has entered the sector with its Vuse product. Philip Morris, the world's largest tobacco firm, purchased UK's Nicocigs in June 2014. On 30 April 2015, Japan Tobacco bought the US Logic e-cigarette brand. Japan Tobacco also bought the UK E-Lites brand in June 2014. On 15 July 2014, Lorillard sold blu to Imperial Tobacco as part of a deal for $7.1 billion.
In 2014, dollar sales of customizable e-cigarettes and e-liquid surpassed sales of cigalikes in the US, despite the fact that customizables are less expensive.
Consumers of e-cigarettes, sometimes called "vapers", have shown passionate support for e-cigarettes that other nicotine replacement therapies did not receive. This suggests e-cigarettes have potential mass appeal that could challenge combustible tobacco's market position.
A subculture of "vapers" has emerged. Members of this emerging subculture often see e-cigarettes as a safer alternative to smoking, and some view it as a hobby. The online forum Electronic Cigarette Forum was one of the first major communities. It and other online forums, such as UKVaper.org, were the origins of the hobby of modding. There are also groups on Facebook and Reddit. Online forums based around modding have grown in the vaping community. Vapers energetically embrace activities associated with e-cigarettes and sometimes act as unpaid evangelists according to a 2014 review. A 2014 Postgraduate Medical Journal editorial stated that e-cigarette companies have a substantial online presence, as well as many individual vapers who blog and tweet about e-cigarette related products. The editorial stated that vapers "also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks". A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda. The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws. The same review said this is similar to tobacco industry activity going back to the 1980s. These approaches were used in Europe to minimize the EU Tobacco Product Directive in October 2013. True grassroots lobbying also influenced the TPD decision.Rebecca Taylor, a member of the European Parliament, stated, "to say it's an orchestrated campaign is absolute rubbish." Contempt for "big tobacco" is part of vaping culture.E-cigarette user blowing a cloud of aerosol (vapor). The activity is known as cloud-chasing.
Large gatherings of vapers, called vape meets, take place around the US. They focus on e-cig devices, accessories, and the lifestyle that accompanies them. Vapefest, which started in 2010, is an annual show hosted by different cities. People attending these meetings are usually enthusiasts that use specialized, community-made products not found in convenience stores or gas stations. These products are mostly available online or in dedicated "vape" storefronts where mainstream e-cigarettes brands from the tobacco industry and larger e-cig manufacturers are not as popular. Some vape shops have a vape bar where patrons can test out different e-liquids and socialize. The Electronic Cigarette Convention in North America which started in 2013, is an annual show where companies and consumers meet up.
A subclass of vapers configure their atomizers to produce large amounts of vapor by using low-resistance heating coils. This practice is called "cloud-chasing" By using a coil with very low resistance, the batteries are stressed to a potentially unsafe extent. This could present a risk of dangerous battery failures. As vaping comes under increased scrutiny, some members of the vaping community have voiced their concerns about cloud-chasing, claiming the practice gives vapers a bad reputation when doing it in public. The Oxford Dictionaries' word of the year for 2014 was "vape".Main articles: Regulation of electronic cigarettes and List of vaping bans in the United States A no smoking or vaping sign from the US.
Regulation of e-cigarettes varies across countries and states, ranging from no regulation to banning them entirely. Others have introduced strict restrictions and some have licensed devices as medicines such as in the UK. As of 2015[update], around two thirds of major nations have regulated e-cigarettes in some way. Because of the potential relationship with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries. The companies that make e-cigarettes have been pushing for laws that support their interests. In 2016 the US Department of Transportation banned the use of e-cigarettes on commercial flights. This regulation applies to all flights to and from the US.
The legal status of e-cigarettes is currently pending in many countries. Many countries such as Brazil, Singapore, the Seychelles, Uruguay, and Norway have banned e-cigarettes. In Canada, they are technically illegal to sell, as no nicotine-containing e-fluid is approved by Health Canada, but this is generally unenforced and they are commonly available for sale Canada-wide. In the US and the UK, the use and sale to adults of e-cigarettes are legal.:US:UK As of August 8, 2016, the FDA extended its regulatory power to include e-cigarettes. Under this ruling the FDA will evaluate certain issues, including ingredients, product features and health risks, as well their appeal to minors and non-users. The FDA rule also bans access to minors. A photo ID is required to buy e-cigarettes, and their sale in all-ages vending machines is not permitted. In May 2016 the FDA used its authority under the Family Smoking Prevention and Tobacco Control Act to deem e-cigarette devices and e-liquids to be tobacco products, which meant it intended to regulate the marketing, labelling, and manufacture of devices and liquids; vape shops that mix e-liquids or make or modify devices were considered manufacturing sites that needed to register with FDA and comply with good manufacturing practice regulation. E-cigarette and tobacco companies have recruited lobbyists in an effort to prevent the FDA from evaluating e-cigarette products or banning existing products already on the market.
In February 2014 the European Parliament passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging. In April 2014 the FDA published proposed regulations for e-cigarettes along similar lines. In the US some states tax e-cigarettes as tobacco products, and some state and regional governments have broadened their indoor smoking bans to include e-cigarettes. As of 9 October 2015, at least 48 states and 2 territories banned e-cigarette sales to minors.
E-cigarettes have been listed as drug delivery devices in several countries because they contain nicotine, and their advertising has been restricted until safety and efficacy clinical trials are conclusive. Since they do not contain tobacco, television advertising in the US is not restricted. Some countries have regulated e-cigarettes as a medical product even though they have not approved them as a smoking cessation aid. A 2014 review stated the emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public and recommended that e-cigarettes should be regulated to protect consumers. It added, "heavy regulation by restricting access to e-cigarettes would just encourage continuing use of much unhealthier tobacco smoking." A 2014 review said these products should be considered for regulation in view of the "reported adverse health effects".
A 2014 review said, "the e-cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to promote cigarettes in the 1950s and 1960s." E-cigarettes and nicotine are regularly promoted as safe and beneficial in the media and on brand websites. While advertising of tobacco products is banned in most countries, television and radio e-cigarette advertising in some countries may be indirectly encouraging traditional cigarette smoking. There is no evidence that the cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some claiming to want to cooperate in "harm reduction". In the US, six large e-cigarette businesses spent $59.3 million on promoting e-cigarettes in 2013. Easily circumvented age verification at company websites enables young people to access and be exposed to marketing for e-cigarettes.
A national US television advertising campaign starred Steven Dorff exhaling a "thick flume" of what the ad describes as "vapor, not tobacco smoke", exhorting smokers with the message "We are all adults here, it's time to take our freedom back." The ads, in a context of longstanding prohibition of tobacco advertising on TV, were criticized by organizations such as Campaign for Tobacco-Free Kids as undermining anti-tobacco efforts. Cynthia Hallett of Americans for Non-Smokers' Rights described the US advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable". University of Pennsylvania communications professor Joseph Cappella stated that the setting of the ad near an ocean was meant to suggest an association of clean air with the nicotine product. In 2012 and 2013, e-cigarette companies advertised to a large television audience in the US which included 24 million youth. The channels on which e-cigarette advertising reached the largest numbers of youth (ages 12–17) were AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.
A 2014 review said e-cigarettes are aggressively promoted, mostly via the internet, as a healthy alternative to smoking in the US.Celebrity endorsements are used to encourage e-cigarette use. "Big tobacco" markets e-cigarettes to young people, with industry strategies including cartoon characters and candy flavors to sell e-cigarettes. E-cigarette companies commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as scientists have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum. The assertion that e-cigarette emit "only water vapor" is false because the evidence indicates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and organic volatile compounds, in addition to particulates.Vaping stand, London shopping centre.
The number of e-cigarettes sold increased every year from 2003 to 2015, when a slowdown in the growth in usage occurred in both the US and the UK. As of 2014[update] there were at least 466 e-cigarette brands. Worldwide e-cigarette sales in 2014 were around US$7 billion. Approximately 30–50% of total e-cigarettes sales are handled on the internet.
As of 2015[update] most e-cigarette devices were made in China, mainly in Shenzhen. Chinese companies' market share of e-liquid is low.
In the US, tobacco producers have a significant share of the e-cigarette market. As of 2015[update], 80% of all e-cigarette sales in convenience stores in the U.S. were products made by tobacco companies. According to Nielsen Holdings, convenience store e-cigarette sales in the US went down for the first time during the four-week period ending on 10 May 2014. Wells Fargo analyst Bonnie Herzog attributes this decline to a shift in consumers' behavior, buying more specialized devices or what she calls "vapor/tank/mods (VTMs)" that are not tracked by Nielsen. Wells Fargo estimated that VTMs accounted for 57% of the 3.5 billion dollar market in the US for vapor products in 2015. In 2014, the Smoke-Free Alternatives Trade Association estimated that there were 35,000 vape shops in the US, more than triple the number a year earlier. However the 2015 slowdown in market growth affected VTMs as well.
In Canada, e-cigarettes had an estimated value of 140 million CAD in 2015. There are numerous e-cigarette retail shops in Canada. A 2014 audit of retailers in four Canadian cities found that 94% of grocery stores, convenience stores, and tobacconist shops which sold e-cigarettes sold nicotine-free varieties only, while all vape shops stocked at least one nicotine-containing product.
In the UK in 2015 the "most prominent brands of cigalikes" were owned by tobacco companies, but except for one model all the tank types came from "non-tobacco industry companies". However some tobacco industry products, while using prefilled cartridges, resemble tank models.
France's electronic cigarette market was estimated by Groupe Xerfi to be €130 million in 2015. Additionally, France's e-liquid market was estimated at €265 million. In December 2015, there were 2,400 vape shops in France, 400 fewer than in March of the same year. Industry organization Fivape said the reduction was due to consolidation, not to reduced demand.
Other devices to deliver inhaled nicotine have been developed. They aim to mimic the ritual and behavioral aspects of traditional cigarettes.
British American Tobacco, through their subsidiary Nicoventures, licensed a nicotine delivery system based on existing asthma inhaler technology from UK-based healthcare company Kind Consumer. In September 2014 a product based on this named Voke obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.
Philip Morris International (PMI) bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University. The technology is based on the chemical reaction between pyruvic acid and nicotine, which produces an inhalable nicotine pyruvate vapor.
PAX Labs has developed vaporizers that heats the leaves of tobacco to deliver nicotine in a vapor. On 1 June 2015, they introduced Juul a different type of e-cigarette which delivers 10 times as much nicotine as other e-cigarettes, equivalent to an actual cigarette puff.
BLOW started selling e-hookahs, an electronic version of the hookah, in 2014. Several companies including Canada's Eagle Energy Vapor are selling caffeine-based e-cigarettes instead of nicotine.
- ^ a b Sullum, Jacob (27 Aug 2015), "Wacky British Idea: Why Not Tell The Truth About E-Cigarettes?", Forbes
- ^ a b c d WHO (2014), Electronic nicotine delivery systems: FCTC/COP/6/10 Rev.1 (PDF), Moscow: World Health Organization, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Sixth session, 13–18 October 2014
- ^ a b "Cambridge study raises fears over e-cigarette adverts for children", Cambridge News, 18 Jan 2016
- ^ Lam on behalf of the Asian-Pacific Society of Respirology; et al. (2014), "Electronic cigarettes: ‘Vaping’ has unproven benefits and potential harm", Respirology, 19: 945–947, PMID 25196968, doi:10.1111/resp.12374
- ^ a b Millar et al. (20 Mar 2016), "Consumer Product Safety Commission Gains New Authority Over Some Nicotine-Containing E-Liquid Packages", The National Law Review CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h i j McRobbie, Hayden; Bullen, Chris; Hartmann-Boyce, Jamie; Hajek, Peter; McRobbie, Hayden (2014). "Electronic cigarettes for smoking cessation and reduction". The Cochrane Library. 12: CD010216. PMID 25515689. doi:10.1002/14651858.CD010216.pub2.
- ^ V.Courtney Broaddus, Robert C Mason, Joel D Ernst, Talmadge E King Jr., Stephen C. Lazarus, John F. Murray, Jay A. Nadel, Arthur Slutsky, Michael Gotway (2015). Murray & Nadel's Textbook of Respiratory Medicine. Elsevier Health Sciences. p. 820. ISBN 0323261930. CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h Ebbert, Jon O.; Agunwamba, Amenah A.; Rutten, Lila J. (2015). "Counseling Patients on the Use of Electronic Cigarettes". Mayo Clinic Proceedings. 90 (1): 128–134. ISSN 0025-6196. PMID 25572196. doi:10.1016/j.mayocp.2014.11.004.
- ^ a b c d e f g Siu, A.L. (22 September 2015). "Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement.". Annals of Internal Medicine. 163: 622–34. PMID 26389730. doi:10.7326/M15-2023.
- ^ a b Harrell, P.T.; Simmons, V.N.; Correa, J.B.; Padhya, T.A.; Brandon, T.H. (4 June 2014). "Electronic Nicotine Delivery Systems ("E-cigarettes"): Review of Safety and Smoking Cessation Efficacy.". Otolaryngology—head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 151: 381–393. PMC 4376316 . PMID 24898072. doi:10.1177/0194599814536847.
- ^ Golub, Justin S.; Samy, Ravi N. (2015). "Preventing or reducing smoking-related complications in otologic and neurotologic surgery". Current Opinion in Otolaryngology & Head and Neck Surgery. 23 (5): 334–340. ISSN 1068-9508. PMID 26339963. doi:10.1097/MOO.0000000000000184.
- ^ a b c d McNeill, A. (August 2015). "E-cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. pp. 77–78.
- ^ a b c d e f Rahman MA, Hann N, Wilson A, Worrall-Carter L (2014). "Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues". Tob Induc Dis. 12 (1): 21. PMC 4350653 . PMID 25745382. doi:10.1186/1617-9625-12-21. CS1 maint: Uses authors parameter (link)
- ^ "DrugFacts: Cigarettes and Other Tobacco Products". National Institute on Drug Abuse. May 2016. Retrieved 29 May 2016.
- ^ a b c d Royal College of Physicians. "Nicotine without smoke: Tobacco harm reduction". rcplondon.ac.uk. Retrieved 8 May 2016.
- ^ a b c "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. US Food and Drug Administration. 81 (90): 28974–29106. 10 May 2016.
- ^ Nutt, DJ; Phillips, LD; Balfour, D; Curran, HV; Dockrell, M; Foulds, J; Fagerstrom, K; Letlape, K; Milton, A; Polosa, R; Ramsey, J; Sweanor, D (2014). "Estimating the harms of nicotine-containing products using the MCDA approach.". European Addiction Research. 20 (5): 218–25. PMID 24714502. doi:10.1159/000360220.
- ^ a b c Caponnetto P.; Russo C.; Bruno C.M.; Alamo A.; Amaradio M.D.; Polosa R. (Mar 2013). "Electronic cigarette: a possible substitute for cigarette dependence". Monaldi archives for chest disease. 79 (1): 12–19. PMID 23741941. doi:10.4081/monaldi.2013.104.
- ^ a b c d e f g h i j k WHO. "Electronic nicotine delivery systems" (PDF). pp. 1–13. Retrieved 28 August 2014.
- ^ a b "E-Cigarette Use Among Youth and Young Adults A Report of the Surgeon General: Fact Sheet" (PDF). United States Department of Health and Human Services. Surgeon General of the United States. 2016. This article incorporates text from this source, which is in the public domain.
- ^ Soneji, S; Barrington-Trimis, J; Wills, T (26 June 2017). "Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults, A Systematic Review and Meta-analysis". JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1488.
- ^ McNeill, A, PH. "Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note". gov.uk. Public Health England. Retrieved 27 May 2016.
- ^ a b c d e f g h i j k l m n o p q r s t u Grana, R; Benowitz, N; Glantz, SA (13 May 2014). "E-cigarettes: a scientific review.". Circulation. 129 (19): 1972–86. PMC 4018182 . PMID 24821826. doi:10.1161/circulationaha.114.007667.
- ^ a b c d e f Cheng, T. (2014). "Chemical evaluation of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii11–ii17. ISSN 0964-4563. PMC 3995255 . PMID 24732157. doi:10.1136/tobaccocontrol-2013-051482.
- ^ a b c d e f g h i Hajek, P.; Etter, J.F.; Benowitz, N.; Eissenberg, T.; McRobbie, H. (31 July 2014). "Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit". Addiction (Abingdon, England). 109 (11): 1801–10. PMC 4487785 . PMID 25078252. doi:10.1111/add.12659.
- ^ a b c d e f g h Britton, John; Bogdanovica, Ilze (15 May 2014). "Electronic cigarettes – A report commissioned by Public Health England" (PDF). Public Health England.
- ^ a b c d e f g Farsalinos, K.E.; Polosa, R. (2014). "Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review". Therapeutic Advances in Drug Safety. 5 (2): 67–86. ISSN 2042-0986. PMC 4110871 . PMID 25083263. doi:10.1177/2042098614524430.
- ^ a b c Burstyn, Igor (2014). "Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks". BMC Public Health. 14 (1): 18. ISSN 1471-2458. PMC 3937158 . PMID 24406205. doi:10.1186/1471-2458-14-18.
- ^ a b c "E-cigarettes: an emerging public health consensus". UK: Public Health England. 2015.
- ^ a b c d e f g Barbara Demick (25 April 2009). "A high-tech approach to getting a nicotine fix". Los Angeles Times.
- ^ a b c Alawsi, F.; Nour, R.; Prabhu, S. (2015). "Are e-cigarettes a gateway to smoking or a pathway to quitting?". BDJ. 219 (3): 111–115. ISSN 0007-0610. PMID 26271862. doi:10.1038/sj.bdj.2015.591.
- ^ a b c d e f Rom, Oren; Pecorelli, Alessandra; Valacchi, Giuseppe; Reznick, Abraham Z. (2014). "Are E-cigarettes a safe and good alternative to cigarette smoking?". Annals of the New York Academy of Sciences. 1340 (1): 65–74. ISSN 0077-8923. PMID 25557889. doi:10.1111/nyas.12609.
- ^ a b "E-cigarette use triples among middle and high school students in just one year". CDC. Retrieved 15 December 2015.
- ^ a b c "Use of electronic cigarettes (vapourisers) among adults in Great Britain" (PDF). ASH UK. May 2015.
- ^ a b Kim, Ki-Hyun; Kabir, Ehsanul; Jahan, Shamin Ara (2016). "Review of electronic cigarettes as tobacco cigarette substitutes: their potential human health impact". Journal of Environmental Science and Health, Part C: 00–00. ISSN 1059-0501. PMID 27635466. doi:10.1080/10590501.2016.1236604.
- ^ a b "Questions & Answers: New rules for tobacco products". European Commission. 26 February 2014.
- ^ a b "FDA's New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products". US Department of Health and Human Services. US Food and Drug Administration. 12 August 2016.
- ^ a b "Backgrounder on WHO report on regulation of e-cigarettes and similar products". 26 August 2014. Retrieved 2 June 2015.
- ^ editor (13 Aug 2015), "Tasty E-Cigs Popular, Scientifically Uncertain", WGCU News NPR
- ^ Kahn, Steven (18 Dec 2015), "The Best Electronic Cigarettes For Beginners", The Gazette Review
- ^ Keenan et al. (9 Sep 2015), "Vape Culture Attracts Teens, Poses Harmful Risks", The Huffington Post CS1 maint: Uses authors parameter (link)
- ^ "Public consultation on legislation in relation to the sale of tobacco products and non-medicinal nicotine delivery systems, including e-cigarettes". Department of Health (Ireland). 2 December 2014. Retrieved 4 October 2016.
- ^ Michael Felberbaum (11 June 2013). "Marlboro Maker To Launch New Electronic Cigarette". The Huffington Post.
- ^ a b Schraufnagel, Dean E.; Blasi, Francesco; Drummond, M. Bradley; Lam, David C. L.; Latif, Ehsan; Rosen, Mark J.; Sansores, Raul; Van Zyl-Smit, Richard (2014). "Electronic Cigarettes. A Position Statement of the Forum of International Respiratory Societies". American Journal of Respiratory and Critical Care Medicine. 190 (6): 611–618. ISSN 1073-449X. PMID 25006874. doi:10.1164/rccm.201407-1198PP.
- ^ a b c Mickle, Tripp (17 November 2015). "E-cig sales rapidly lose steam". E-Cigarette Sales Rapidly Lose Steam. Retrieved 6 December 2015.
- ^ a b West, Robert; Beard, Emma; Brown, Jamie (10 August 2015). "Electronic cigarettes in England – latest trends (STS140122)". Smoking in England. Retrieved 6 December 2015.
- ^ a b c d e Carroll Chapman, SL; Wu, LT (18 Mar 2014). "E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.". Journal of Psychiatric Research. 54: 43–54. PMC 4055566 . PMID 24680203. doi:10.1016/j.jpsychires.2014.03.005.
- ^ a b c Bullen, Christopher (2014). "Electronic Cigarettes for Smoking Cessation". Current Cardiology Reports. 16 (11): 538. ISSN 1523-3782. PMID 25303892. doi:10.1007/s11886-014-0538-8.
- ^ a b Born, H.; Persky, M.; Kraus, D.H.; Peng, R.; Amin, M.R.; Branski, R.C. (2015). "Electronic Cigarettes: A Primer for Clinicians". Otolaryngology – Head and Neck Surgery. 153: 5–14. ISSN 0194-5998. PMID 26002957. doi:10.1177/0194599815585752.
- ^ a b c d e f g h i Pepper, J. K.; Brewer, N. T. (2013). "Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review". Tobacco Control. 23 (5): 375–384. ISSN 0964-4563. PMC 4520227 . PMID 24259045. doi:10.1136/tobaccocontrol-2013-051122.
- ^ Suter, Melissa A.; Mastrobattista, Joan; Sachs, Maike; Aagaard, Kjersti (2015). "Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (3): 186–195. ISSN 1542-0752. PMC 4830434 . PMID 25366492. doi:10.1002/bdra.23333.
- ^ Franck, C.; Budlovsky, T.; Windle, S.B.; Filion, K. B.; Eisenberg, M.J. (2014). "Electronic Cigarettes in North America: History, Use, and Implications for Smoking Cessation". Circulation. 129 (19): 1945–1952. ISSN 0009-7322. PMID 24821825. doi:10.1161/CIRCULATIONAHA.113.006416.
- ^ Charlotte A. Schoenborn, Renee M. Gindi (October 2015). "Electronic Cigarette Use Among Adults: United States, 2014" (PDF). Centers for Disease Control and Prevention. pp. 1–8. CS1 maint: Uses authors parameter (link)
- ^ a b c d Delnevo, Cristine D.; Giovenco, Daniel P.; Steinberg, Michael B.; Villanti, Andrea C.; Pearson, Jennifer L.; Niaura, Raymond S.; Abrams, David B. (2 November 2015). "Patterns of Electronic Cigarette Use Among Adults in the United States". Nicotine & Tobacco Research. 18: ntv237. doi:10.1093/ntr/ntv237.
- ^ Volkow, Nora (August 2015). "Teens Using E-cigarettes More Likely to Start Smoking Tobacco". National Institute on Drug Abuse.
- ^ a b Lauterstein, Dana; Hoshino, Risa; Gordon, Terry; Watkins, Beverly-Xaviera; Weitzman, Michael; Zelikoff, Judith (2014). "The Changing Face of Tobacco Use Among United States Youth". Current Drug Abuse Reviews. 7 (1): 29–43. ISSN 1874-4737. PMC 4469045 . PMID 25323124. doi:10.2174/1874473707666141015220110.
- ^ a b Hildick-Smith, Gordon J.; Pesko, Michael F.; Shearer, Lee; Hughes, Jenna M.; Chang, Jane; Loughlin, Gerald M.; Ipp, Lisa S. (2015). "A Practitioner's Guide to Electronic Cigarettes in the Adolescent Population". Journal of Adolescent Health. 57: 574–9. ISSN 1054-139X. PMID 26422289. doi:10.1016/j.jadohealth.2015.07.020.
- ^ Sabrina Tavernise (17 April 2015). "Use of e-cigarettes rising sharply among teenagers". Boston Globe.
- ^ a b c d Schraufnagel, Dean E. (2015). "Electronic Cigarettes: Vulnerability of Youth". Pediatric Allergy, Immunology, and Pulmonology. 28 (1): 2–6. ISSN 2151-321X. PMC 4359356 . PMID 25830075. doi:10.1089/ped.2015.0490.
- ^ "Monitoring the Future Survey, Overview of Findings 2015". National Institute on Drug Abuse. Retrieved 10 March 2016.
- ^ Arrazola, RA; Neff, LJ; Kennedy, SM; Holder-Hayes, E; Jones, CD (14 November 2014). "Tobacco Use Among Middle and High School Students — United States, 2013". MMWR Morb. Mortal. Wkly. Rep. 63 (45): 1021–1026. PMID 24699766.
- ^ a b Cooke, Andrew; Fergeson, Jennifer; Bulkhi, Adeeb; Casale, Thomas B. (2015). "The Electronic Cigarette: The Good, the Bad, and the Ugly". The Journal of Allergy and Clinical Immunology: In Practice. 3 (4): 498–505. ISSN 2213-2198. PMID 26164573. doi:10.1016/j.jaip.2015.05.022.
- ^ Centers for Disease Control and Prevention (CDC) (November 2013). "Tobacco product use among middle and high school students—United States, 2011 and 2012". MMWR Morb. Mortal. Wkly. Rep. 62 (45): 893–7. PMID 24226625.
- ^ a b McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. Retrieved 19 August 2015.
- ^ a b c "Use of electronic cigarettes in Great Britain" (PDF). ASH. ASH. July 2014. Retrieved 18 September 2014.
- ^ "Over 2 million Britons now regularly use electronic cigarettes". ASH UK. 28 April 2014. Retrieved 30 May 2014.
- ^ McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. pp. 31–34. Retrieved 25 August 2015.
- ^ Moore, G. F.; Littlecott, H. J.; Moore, L.; Ahmed, N.; Holliday, J. (2014). "E-cigarette use and intentions to smoke among 10-11-year-old never-smokers in Wales". Tobacco Control. 25: 147–52. ISSN 0964-4563. PMC 4789807 . PMID 25535293. doi:10.1136/tobaccocontrol-2014-052011.
- ^ a b c "Prévalence, comportements d'achat et d'usage, motivations des utilisateurs de la cigarette électronique" (PDF). Observatoire Français des Drogues et des Toxicomanies. 12 February 2014. Retrieved 28 March 2014.
- ^ a b c Brandon, T.H.; Goniewicz, M.L.; Hanna, N.H.; Hatsukami, D.K.; Herbst, R.S.; Hobin, J.A.; Ostroff, J.S.; Shields, P.G.; Toll, B.A.; Tyne, C.A.; Viswanath, K.; Warren, G.W. (2015). "Electronic Nicotine Delivery Systems: A Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology" (PDF). Clinical Cancer Research. 21: 514–525. ISSN 1078-0432. PMID 25573384. doi:10.1158/1078-0432.CCR-14-2544.
- ^ Zhong, Jieming; Cao, Shuangshuang; Gong, Weiwei; Fei, Fangrong; Wang, Meng (3 May 2016). "Electronic Cigarettes Use and Intention to Cigarette Smoking among Never-Smoking Adolescents and Young Adults: A Meta-Analysis". International Journal of Environmental Research and Public Health. 13 (5): 465. doi:10.3390/ijerph13050465.
- ^ a b "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original on 6 November 2014. CS1 maint: BOT: original-url status unknown (link)
- ^ a b c Grana R.A., Ling P.M. (2014). ""Smoking revolution": a content analysis of electronic cigarette retail websites". Am J Prev Med. 46 (4): 395–403. PMC 3989286 . PMID 24650842. doi:10.1016/j.amepre.2013.12.010. CS1 maint: Uses authors parameter (link)
- ^ a b Tomashefski, A (21 March 2016). "The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review.". Journal of the American Association of Nurse Practitioners. PMID 26997487. doi:10.1002/2327-6924.12358.
- ^ a b c d e Orellana-Barrios, Menfil A.; Payne, Drew; Mulkey, Zachary; Nugent, Kenneth (2015). "Electronic cigarettes-a narrative review for clinicians". The American Journal of Medicine. 128: 674–81. ISSN 0002-9343. PMID 25731134. doi:10.1016/j.amjmed.2015.01.033.
- ^ a b Crowley, Ryan A. (2015). "Electronic Nicotine Delivery Systems: Executive Summary of a Policy Position Paper From the American College of Physicians". Annals of Internal Medicine. 162 (8): 583–4. ISSN 0003-4819. PMID 25894027. doi:10.7326/M14-2481.
- ^ a b c England, Lucinda J.; Bunnell, Rebecca E.; Pechacek, Terry F.; Tong, Van T.; McAfee, Tim A. (2015). "Nicotine and the Developing Human". American Journal of Preventive Medicine. 49: 286–93. ISSN 0749-3797. PMC 4594223 . PMID 25794473. doi:10.1016/j.amepre.2015.01.015.
- ^ a b Linda Bauld; Kathryn Angus; Marisa de Andrade (May 2014). "E-cigarette uptake and marketing" (PDF). Public Health England. pp. 1–19.
- ^ Kong, G.; Morean, M.E.; Cavallo, D.A.; Camenga, D.R.; Krishnan-Sarin, S. (2014). "Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults". Nicotine & Tobacco Research. 17: 847–54. ISSN 1462-2203. PMC 4674436 . PMID 25481917. doi:10.1093/ntr/ntu257.
- ^ "Heart and Stroke Foundation: E-cigarettes in Canada". Heart and Stroke Foundation.
- ^ Kevin Chatham-Stephens (20 October 2014). "Young Children and e-Cigarette Poisoning". Medscape.
- ^ a b Yingst, J. M.; Veldheer, S.; Hrabovsky, S.; Nichols, T. T.; Wilson, S. J.; Foulds, J. (2015). "Factors associated with electronic cigarette users' device preferences and transition from first generation to advanced generation devices.". Nicotine Tob Res. 17: 1242–6. ISSN 1462-2203. PMC 4592341 . PMID 25744966. doi:10.1093/ntr/ntv052.
- ^ a b Sanford Z, Goebel L (2014). "E-cigarettes: an up to date review and discussion of the controversy". W V Med J. 110 (4): 10–5. PMID 25322582. CS1 maint: Uses authors parameter (link)
- ^ a b c d e f g h i Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015-08-01). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. ISSN 1660-4601. PMC 4555324 . PMID 26308021. doi:10.3390/ijerph120809988.
- ^ Abuse, National Institute on Drug. "Electronic Cigarettes (e-Cigarettes)". drugabuse.gov. Retrieved 2016-01-27.
- ^ Giroud, Christian; de Cesare, Mariangela; Berthet, Aurélie; Varlet, Vincent; Concha-Lozano, Nicolas; Favrat, Bernard (2015-08-01). "E-Cigarettes: A Review of New Trends in Cannabis Use". International Journal of Environmental Research and Public Health. 12 (8): 9988–10008. ISSN 1661-7827. PMC 4555324 . PMID 26308021. doi:10.3390/ijerph120809988.
- ^ "Electronic Cigarette Fires and Explosions" (PDF). U.S. Fire Administration. 2014. pp. 1–11.
- ^ "What is an e-Cigarette MOD E-cig 101". 19 February 2014.
- ^ "Vaper Talk – The Vaper's Glossary". Spinfuel eMagazine. 5 July 2013. Retrieved 18 November 2014.
- ^ a b c Rowell, Temperance R.; Tarran, Robert (2015). "Will Chronic E-Cigarette Use Cause Lung Disease?". American Journal of Physiology. Lung Cellular and Molecular Physiology. 309: ajplung.00272.2015. ISSN 1040-0605. PMC 4683316 . PMID 26408554. doi:10.1152/ajplung.00272.2015.
- ^ a b c Caponnetto, Pasquale; Campagna, Davide; Papale, Gabriella; Russo, Cristina; Polosa, Riccardo (2012). "The emerging phenomenon of electronic cigarettes". Expert Review of Respiratory Medicine. 6 (1): 63–74. ISSN 1747-6348. PMID 22283580. doi:10.1586/ers.11.92.
- ^ Glasser, A. M.; Cobb, C. O.; Teplitskaya, L.; Ganz, O.; Katz, L.; Rose, S. W.; Feirman, S.; Villanti, A. C. (2015). "Electronic nicotine delivery devices, and their impact on health and patterns of tobacco use: a systematic review protocol". BMJ Open. 5 (4): e007688–e007688. ISSN 2044-6055. PMC 4420972 . PMID 25926149. doi:10.1136/bmjopen-2015-007688.
- ^ a b c d Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, Voudris V (2014). "Nicotine absorption from electronic cigarette use: Comparison between first and new-generation devices". Scientific Reports. 4: 4133. PMC 3935206 . PMID 24569565. doi:10.1038/srep04133.
- ^ a b c Bhatnagar, A.; Whitsel, L. P.; Ribisl, K. M.; Bullen, C.; Chaloupka, F.; Piano, M.R.; Robertson, R. M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "AHA Policy Statement - Electronic Cigarettes". Circulation. 130 (16): 1418–1436. PMID 25156991. doi:10.1161/cir.0000000000000107. Archive
- ^ Hayden McRobbie (2014). "Electronic cigarettes" (PDF). National Centre for Smoking Cessation and Training. pp. 1–16.
- ^ Konstantinos Farsalinos. "Electronic cigarette evolution from the first to fourth generation and beyond" (PDF). gfn.net.co. Global Forum on Nicotine. p. 23. Retrieved 23 September 2015.
- ^ a b c d e Garner, Charles; Stevens, Robert (February 2014). "A Brief Description of History, Operation and Regulation" (PDF). Coresta. Retrieved 21 February 2016.
- ^ a b c Oh, Anne Y.; Kacker, Ashutosh (December 2014). "Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes?: Review on e-cigarette vapor versus tobacco smoke". The Laryngoscope. 124 (12): 2702–2706. PMID 25302452. doi:10.1002/lary.24750.
- ^ Jimenez Ruiz, CA; Solano Reina, S; de Granda Orive, JI; Signes-Costa Minaya, J; de Higes Martinez, E; Riesco Miranda, JA; Altet Gómez, N; Lorza Blasco, JJ; Barrueco Ferrero, M; de Lucas Ramos, P (August 2014). "The electronic cigarette. Official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes.". Archivos de bronconeumologia. 50 (8): 362–7. PMID 24684764. doi:10.1016/j.arbres.2014.02.006.
- ^ a b John Reid Blackwell. "Avail Vapor offers glimpse into the 'art and science' of e-liquids". Richmond Times-Dispatch. Retrieved 23 November 2015.
- ^ E-Liquid Manufacturing Standards (PDF). US: AMERICAN E-LIQUID MANUFACTURING STANDARDS ASSOCIATION (AEMSA). 2015. pp. 1–13.
- ^ "More than a quarter-million youth who had never smoked a cigarette used e-cigarettes in 2013". Centers for Disease Control and Prevention. Retrieved 8 July 2015.
- ^ a b c Framework Convention Alliance on Tobacco Control. "FCA Policy briefing Electronic Nicotine Delivery Systems" (PDF). fctc.org. Retrieved 2 March 2016.
- ^ a b "Electronic Cigarettes (e-Cigarettes)". US Food and Drug Administration. Retrieved 6 November 2014.
- ^ a b c d McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 15. Retrieved 24 August 2015.
- ^ National Centre for Smoking Cessation and Training. "Electronic cigarettes: A briefing for stop smoking services". ncsct.co.uk. Retrieved 2 March 2016.
- ^ a b WHO (August 2016). "Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS)" (PDF). pp. 1–11.
- ^ "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. Retrieved 6 November 2014.
- ^ a b McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 76. Retrieved 19 August 2015.
- ^ a b "Electronic cigarettes". Smokefree NHS. Are e-cigarettes safe to use?. Retrieved 28 October 2015.
- ^ "Stop smoking treatments". UK National Health Service. Retrieved 6 November 2014.
- ^ Royal College of Physicians. "Promote e-cigarettes widely as substitute for smoking says new RCP report". rcplondon.ac.uk. Retrieved 7 May 2017.
- ^ "E-cigarette Ads and Youth". Centers for Disease Control and Prevention. Retrieved 26 January 2016.
- ^ "Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions". United States Preventive Services Task Force. Retrieved 3 March 2016.
- ^ "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. August 2015. Retrieved 19 April 2016.
- ^ Farber HJ, Walley SC, Groner JA, Nelson KE (2015). "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" (PDF). Pediatrics. 136 (5): 1008–1017. ISSN 0031-4005. PMID 26504137. doi:10.1542/peds.2015-3108. CS1 maint: Multiple names: authors list (link)
- ^ a b c d e Bhatnagar, A.; Whitsel, L.P.; Ribisl, K.M.; Bullen, C.; Chaloupka, F.; Piano, M.R.; Robertson, R.M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "Electronic Cigarettes: A Policy Statement From the American Heart Association". Circulation. 130 (16): 1418–1436. PMID 25156991. doi:10.1161/CIR.0000000000000107.
- ^ "CDC launches powerful new ads in 'Tips From Former Smokers' campaign". Centers for Disease Control and Prevention. 26 March 2015.
- ^ Knight-West, O; Bullen, C (2016). "E-cigarettes for the management of nicotine addiction.". Substance Abuse and Rehabilitation. 7: 111–8. PMC 4993405 . PMID 27574480. doi:10.2147/SAR.S94264.
- ^ Glasser, AM; Collins, L; Pearson, JL; Abudayyeh, H; Niaura, RS; Abrams, DB; Villanti, AC (30 November 2016). "Overview of Electronic Nicotine Delivery Systems: A Systematic Review.". American journal of preventive medicine. PMID 27914771. doi:10.1016/j.amepre.2016.10.036.
- ^ El Dib, R; Suzumura, EA; Akl, EA; Gomaa, H; Agarwal, A; Chang, Y; Prasad, M; Ashoorion, V; Heels-Ansdell, D; Maziak, W; Guyatt, G (23 February 2017). "Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis.". BMJ Open. 7 (2): e012680. PMC 5337697 . PMID 28235965. doi:10.1136/bmjopen-2016-012680.
- ^ a b c Kalkhoran, Sara; Glantz, Stanton A (2016). "E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis". The Lancet Respiratory Medicine. 4: 116–128. PMID 26776875. doi:10.1016/s2213-2600(15)00521-4.
- ^ a b c Rahman, Muhammad Aziz (30 March 2015). "E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis". PLOS ONE. 10: e0122544. PMC 4378973 . PMID 25822251. doi:10.1371/journal.pone.0122544.
- ^ Khoudigian, S; Devji, T; Lytvyn, L; Campbell, K; Hopkins, R; O'Reilly, D (29 January 2016). "The efficacy and short-term effects of electronic cigarettes as a method for smoking cessation: a systematic review and a meta-analysis.". International journal of public health. 61: 257–67. PMID 26825455. doi:10.1007/s00038-016-0786-z.
- ^ Malas, M; van der Tempel, J; Schwartz, R; Minichiello, A; Lightfoot, C; Noormohamed, A; Andrews, J; Zawertailo, L; Ferrence, R (25 April 2016). "Electronic Cigarettes for Smoking Cessation: A Systematic Review.". Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco: ntw119. PMID 27113014. doi:10.1093/ntr/ntw119.
- ^ Orellana-Barrios, MA; Payne, D; Medrano-Juarez, RM; Yang, S; Nugent, K (October 2016). "Electronic Cigarettes for Smoking Cessation.". The American journal of the medical sciences. 352 (4): 420–426. PMID 27776725. doi:10.1016/j.amjms.2016.07.013.
- ^ a b Hartmann-Boyce, Jamie; McRobbie, Hayden; Bullen, Chris; Begh, Rachna; Stead, Lindsay F; Hajek, Peter; Hartmann-Boyce, Jamie (2016). "Electronic cigarettes for smoking cessation". Cochrane Database Syst Rev. 9: CD010216. PMID 27622384. doi:10.1002/14651858.CD010216.pub3.
- ^ a b c d e f Cahn, Z.; Siegel, M. (February 2011). "Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes?". Journal of public health policy. 32 (1): 16–31. PMID 21150942. doi:10.1057/jphp.2010.41.
- ^ Saitta, D.; Ferro, G.A.; Polosa, R. (3 February 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic Advances in Chronic Disease. 5 (2): 6. PMC 3926346 . PMID 24587890. doi:10.1177/2040622314521271.
- ^ Weaver, Michael; Breland, Alison; Spindle, Tory; Eissenberg, Thomas (2014). "Electronic Cigarettes". Journal of Addiction Medicine. 8 (4): 234–240. ISSN 1932-0620. PMC 4123220 . PMID 25089953. doi:10.1097/ADM.0000000000000043.
- ^ Franck, C; Filion, KB; Kimmelman, J; Grad, R; Eisenberg, MJ (17 May 2016). "Ethical considerations of e-cigarette use for tobacco harm reduction.". Respiratory Research. 17 (1): 53. PMC 4869264 . PMID 27184265. doi:10.1186/s12931-016-0370-3.
- ^ a b c Drummond, M.B.; Upson, D (February 2014). "Electronic cigarettes: Potential harms and benefits". Annals of the American Thoracic Society. 11 (2): 236–42. PMID 24575993. doi:10.1513/annalsats.201311-391fr.
- ^ McNeill, A, SC (2015). "E – cigarettes: an evidence update A report commissioned by Public Health England" (PDF). gov.uk. UK: Public Health England. p. 65. Retrieved 20 August 2015.
- ^ a b c d Saitta, D; Ferro, GA; Polosa, R (Mar 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic advances in chronic disease. 5 (2): 50–61. PMC 3926346 . PMID 24587890. doi:10.1177/2040622314521271.
- ^ a b Nowak D, Jörres RA, Rüther T (2014). "E-cigarettes—prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. PMC 4047602 . PMID 24882626. doi:10.3238/arztebl.2014.0349. CS1 maint: Uses authors parameter (link)
- ^ "BMA calls for stronger regulation of e-cigarettes" (PDF). British Medical Association. Retrieved 18 November 2013.
- ^ "Principles to Guide AAPHP Tobacco Policy". American Association of Public Health Physicians. Retrieved 31 July 2013.
- ^ a b c Edgar, Julie. "E-Cigarettes: Expert Q&A With the CDC". WebMD. Retrieved 17 November 2013.
- ^ Detailed reference list is located on a separate image page.
- ^ Cancer Research UK. "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). cancerresearchuk.org. Retrieved 20 March 2016.
- ^ Odum, L.E.; O'Dell, K.A.; Schepers, J.S. (December 2012). "Electronic cigarettes: do they have a role in smoking cessation?". Journal of pharmacy practice. 25 (6): 611–4. PMID 22797832. doi:10.1177/0897190012451909.
- ^ O'Connor, R.J. (March 2012). "Non-cigarette tobacco products: what have we learnt and where are we headed?". Tobacco control. 21 (2): 181–90. PMC 3716250 . PMID 22345243. doi:10.1136/tobaccocontrol-2011-050281.
- ^ Farsalinos, Konstantinos E; Le Houezec, Jacques (29 September 2015). "Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)". Risk Management and Healthcare Policy. 8: 157–167. PMC 4598199 . PMID 26457058. doi:10.2147/RMHP.S62116.
- ^ Polosa R, Campagna D, Caponnetto P (2015). "What to advise to respiratory patients intending to use electronic cigarettes". Discov Med. 20 (109): 155–61. PMID 26463097.
- ^ Polosa R (2015). "Electronic cigarette use and harm reversal: emerging evidence in the lung". BMC Med. 13: 54. PMC 4365531 . PMID 25857426. doi:10.1186/s12916-015-0298-3.
- ^ "The Potential Adverse Health Consequences of Exposure to Electronic Cigarettes and Electronic Nicotine Delivery Systems". Oncology Nursing Forum. 42 (5): 445–446. 2015. ISSN 0190-535X. PMID 26302273. doi:10.1188/15.ONF.445-446.
- ^ a b c Durmowicz, E.L. (2014). "The impact of electronic cigarettes on the paediatric population". Tobacco Control. 23 (Supplement 2): ii41–ii46. ISSN 0964-4563. PMC 3995262 . PMID 24732163. doi:10.1136/tobaccocontrol-2013-051468.
- ^ a b Bertholon, J.F.; Becquemin, M.H.; Annesi-Maesano, I.; Dautzenberg, B. (2013). "Electronic Cigarettes: A Short Review". Respiration. 86: 433–8. ISSN 1423-0356. PMID 24080743. doi:10.1159/000353253.
- ^ McNeill, A, PH. "Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note". gov.uk. Public Health England. Retrieved 27 May 2016.
- ^ a b Polosa, R.; Campagna, D.; Caponnetto, P. (September 2015). "What to advise to respiratory patients intending to use electronic cigarettes". Discovery medicine. 20 (109): 155–61. PMID 26463097.
- ^ Kosmider, Leon; et al. (September 2014). "Carbonyl Compounds in Electronic Cigarette Vapors: Effects of Nicotine Solvent and Battery Output Voltage". Nicotine & Tobacco Research. 16 (10): 1319–1326. ISSN 1462-2203. PMID 24832759. doi:10.1093/ntr/ntu078.
- ^ a b Jerry JM, Collins GB, Streem D (2015). "E-cigarettes: Safe to recommend to patients?". Cleve Clin J Med. 82 (8): 521–6. PMID 26270431. doi:10.3949/ccjm.82a.14054. CS1 maint: Uses authors parameter (link)
- ^ "The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014, Chapter 5 - Nicotine" (PDF). Surgeon General of the United States. 2014. pp. 107–138.
- ^ Benowitz, NL; Fraiman, JB (23 March 2017). "Cardiovascular effects of electronic cigarettes.". Nature Reviews Cardiology. PMID 28332500. doi:10.1038/nrcardio.2017.36.
- ^ Pisinger, Charlotta; Døssing, Martin (December 2014). "A systematic review of health effects of electronic cigarettes". Preventive Medicine. 69: 248–260. PMID 25456810. doi:10.1016/j.ypmed.2014.10.009.
- ^ Chang, H. (2014). "Research gaps related to the environmental impacts of electronic cigarettes". Tobacco Control. 23 (Supplement 2): ii54–ii58. ISSN 0964-4563. PMC 3995274 . PMID 24732165. doi:10.1136/tobaccocontrol-2013-051480.
- ^ Public Health England. "E-cigarettes in public places and workplaces: a 5-point guide to policy making". uk.gov. Retrieved 7 May 2017.
- ^ Hess, IM; Lachireddy, K; Capon, A (15 April 2016). "A systematic review of the health risks from passive exposure to electronic cigarette vapour.". Public health research & practice. 26 (2). PMID 27734060. doi:10.17061/phrp2621617.
- ^ "State Health Officer's Report on E-Cigarettes: A Community Health Threat" (PDF). California Department of Public Health, California Tobacco Control Program. January 2015.
- ^ Linda J. Vorvick (2013-08-29). "Nicotine and Tobacco". Medline Plus. Retrieved 2015-05-21.
- ^ Palazzolo, Dominic L. (Nov 2013). "Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review.". Frontiers in Public Health. 1 (56). PMC 3859972 . PMID 24350225. doi:10.3389/fpubh.2013.00056.
- ^ a b Schroeder, M.J.; Hoffman, A.C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. ISSN 0964-4563. PMC 3995273 . PMID 24732160. doi:10.1136/tobaccocontrol-2013-051469.
- ^ a b "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. September 2014. Retrieved 15 October 2014.
- ^ Evans, S.E.; Hoffman, A.C. (2014). "Electronic cigarettes: abuse liability, topography and subjective effects". Tobacco Control. 23 (Supplement 2): ii23–ii29. ISSN 0964-4563. PMC 3995256 . PMID 24732159. doi:10.1136/tobaccocontrol-2013-051489.
- ^ Centers for Disease Control and Prevention, (CDC) (6 September 2013). "Notes from the field: electronic cigarette use among middle and high school students – United States, 2011–2012". MMWR. Morbidity and mortality weekly report. 62 (35): 729–30. PMID 24005229.
- ^ "Teens like different forms of tobacco and nicotine". American Cancer Society. Archived from the original on 20 September 2015. Retrieved 18 August 2015.
- ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013.
- ^ Korioth, Trisha. "E-cigarettes easy to buy, can hook kids on nicotine". The American Academy of Pediatrics. Retrieved 17 November 2013.
- ^ "FDA Warns of Health Risks Posed by E-Cigarettes". FDA. 23 July 2009. Retrieved 17 November 2013—Reviewed 17 September 2013
- ^ Goniewicz, Maciej L.; Hajek, Peter; McRobbie, Hayden (2014). "Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications" (PDF). Addiction. 109 (3): 500–507. ISSN 0965-2140. PMID 24345184. doi:10.1111/add.12410.
- ^ Noah Charney (7 December 2014). "America's vaping revolution: How suspicious should we really be of the e-cigarette craze?". Salon magazine.
- ^ "US Patent 3200819. Smokeless non-tobacco cigarette". Retrieved 29 February 2012.
- ^ a b c Mary Bellis (2015). "Who Invented Electronic Cigarettes?". About.com.
- ^ a b P.H. (17 March 2014). "A case of the vapers". The Economist.
- ^ Julie Beck (13 June 2014). "Schrödinger's Cigarette: Is Electronic Safer?". The Atlantic.
- ^ Millstein, Seth (25 April 2009). "The Push to Ban E-Cigarettes: Where's the Proof?". TimeLine. Archived from the original on 2 July 2015. Retrieved 18 February 2016.
- ^ "Electronic Cigarette Sales on the Rise". WalesOnline. 24 August 2011.
- ^ a b c d Sridi, Nicolas (10 July 2013). "I was sure that the electronic cigarette would be welcomed with open arms". Sciences et Avenir.
- ^ "Electronic Atomization Cigarette". Worldwide.espacenet.com. 22 November 2007.
- ^ a b "Dragonite Sells E-Vapor Business To ITG". Convenient Store Decisions. 21 August 2013.
- ^ Tom Hancock (1 October 2013). "China's e-cigarette inventor fights for financial rewards". Fox News Channel.
- ^ a b c d e f g Michael Grothaus (1 October 2014). "Trading addictions: the inside story of the e-cig modding scene". Engadget.
- ^ a b Annabel Denham (10 June 2013). "Brothers who took a punt on a new market". CityAM. Retrieved 4 April 2014.
- ^ a b c d e f g Mike K (9 June 2015). "What Does The Future Hold For Vaping Technology?". Steve K's Vaping World.
- ^ Akam, Simon (27 May 2015). "Big Tobacco fights back: how the cigarette kings bought the vaping industry". Newsweek. Retrieved 22 February 2016.
- ^ "Kodak moment". The Economist. 28 September 2013. Retrieved 11 March 2014.
- ^ a b Mike Esterl (3 February 2014). "Altria Expands in E-Cigarettes With Green Smoke". The Wall Street Journal. Retrieved 7 March 2014.
- ^ Brian Montopoli (11 June 2013). "Tobacco companies bet on electronic cigarettes". CBS News. Retrieved 16 August 2013.
- ^ Sanchez Manning (29 July 2013). "British American Tobacco enters electronic cigarette market in Britain with the 'Vype'". The Independent.
- ^ Gustafsson, Katarina (2 September 2013). "Imperial Tobacco Agrees to Acquire Dragonite's E-Cigarette Unit". Bloomberg. Retrieved 20 November 2013.
- ^ "Lorillard, Inc. Acquires British-based SKYCIG, Expanding its Electronic Cigarette Business". Retrieved 1 October 2013.
- ^ "Lorillard to Rebrand SKYCIG as blu eCigs". Convenience Store News. 27 March 2014.
- ^ a b "Altria Completes Acquisition of Green Smoke". BusinessWire. 1 April 2014. Retrieved 21 November 2014.
- ^ Gideon Spanier (26 June 2014). "Philip Morris buys e-cigarette maker Nicocigs as it warns of falling profits". The Independent.
- ^ a b "Japan Tobacco's Global Ambitions Lead to Logic Acquisition". Convenience Store News. 30 April 2015.
- ^ Mangan, Dan (15 July 2014). "Feeling blu? E-cig company spun off in major tobacco deal". CNBC.
- ^ Koebler, Jason (25 September 2014). "Big Tobacco Has Officially Lost Its Hold on the E-Cigarette Market". Motherboard. Retrieved 25 February 2016.
- ^ a b c d e Couts, Andrew (13 May 2013). "Inside the world of vapers, the subculture that might save smokers' lives". Digital Trends. Retrieved 20 November 2013.
- ^ Park, Andy (26 August 2013). "The Feed: The subculture around e-cigarettes". SBS World News. Retrieved 20 November 2013.
- ^ Barbeau, Amanda M; Burda, Jennifer; Siegel, Michael (2013). "Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach". Addiction Science & Clinical Practice. 8 (1): 5. ISSN 1940-0640. PMC 3599549 . PMID 23497603. doi:10.1186/1940-0640-8-5.
- ^ a b Eric Larson (25 January 2014). "Pimp My Vape: The Rise of E-Cigarette Hackers". Mashable. Retrieved 22 November 2014.
- ^ Molly Osberg (25 February 2014). "CVape life: welcome to the weird world of e-cig evangelists". The Verge.
- ^ a b McKee, M. (2014). "Electronic cigarettes: peering through the smokescreen" (PDF). Postgraduate Medical Journal. 90 (1069): 607–609. ISSN 0032-5473. PMID 25294933. doi:10.1136/postgradmedj-2014-133029.
- ^ a b Jacobs, Emma; Robinson, Duncan (17 April 2014). "E-cigarettes: no smoke without fear". FT Magazine. Retrieved 11 January 2016.
- ^ Tom Gara (14 April 2014). "Are E-Cigarettes Losing Ground in the Vapor Market?". The Wall Street Journal.
- ^ Sottile, Leah (8 October 2014). "The Right to Vape". The Atlantic. Retrieved 28 February 2016.
- ^ Gavin Haynes (22 April 2015). "Daft vapers: the competitive world of e-cigarette smoking". The Guardian.
- ^ Mike Esterl (29 May 2014). "'Vaporizers' Are the New Draw in E-Cigarettes". The Wall Street Journal.
- ^ Staff (13 February 2014). "Generation V E-Cigarettes and Vape Bar aims to convert smokers to e-cigarettes". Daily Nebraskan.
- ^ Neil Nisperos (4 September 2014). "Vaping convention coming to Ontario Convention Center Friday". Inland Valley Daily Bulletin.
- ^ Mary Plass (29 January 2014). "The Cloud Chasers". Vape News Magazine.
- ^ a b c Sean Cooper (23 May 2014). "What you need to know about vaporizers". Engadget.
- ^ Dominique Mosbergen (5 August 2014). "This Man Is An Athlete In The Sport Of 'Cloud Chasing'". The Huffington Post.
- ^ Victoria Bekiempis (1 April 2015). "Veteran E-Cigarette Users Fret 'Cloud Chasers' Give Them a Bad Name". Newsweek.
- ^ Fallon, Claire (19 November 2014). "'Vape' Is Oxford Dictionaries' Word Of The Year". The Huffington Post.
- ^ Etter, J. F.; Bullen, C.; Flouris, A. D.; Laugesen, M.; Eissenberg, T. (May 2011). "Electronic nicotine delivery systems: a research agenda". Tobacco control. 20 (3): 243–8. PMC 3215262 . PMID 21415064. doi:10.1136/tc.2010.042168.
- ^ a b Beard, Emma; Shahab, Lion; Cummings, Damian M.; Michie, Susan; West, Robert (2016). "New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?". CNS Drugs. ISSN 1172-7047. PMID 27421270. doi:10.1007/s40263-016-0362-3.
- ^ Barnaby Page (5 March 2015). "World's law-makers favour basing e-cig rules on tobacco". ECigIntelligence. Tamarind Media Limited.
- ^ Lempert, Lauren K; Grana, Rachel; Glantz, Stanton A (2016). "The importance of product definitions in US e-cigarette laws and regulations". Tobacco Control. 25 (e1): e44–e51. ISSN 0964-4563. PMC 4466213 . PMID 25512432. doi:10.1136/tobaccocontrol-2014-051913.
- ^ a b "U.S. Department of Transportation Explicitly Bans the Use of Electronic Cigarettes on Commercial Flights". March 2, 2016. Retrieved 3 March 2016.
- ^ Sienuic, Kat (29 September 2014). "Public health officers tackle hazy issue of e-cigarettes". The Globe and Mail.
- ^ Kadowaki, Joy; Vuolo, Mike; Kelly, Brian C. (2015). "A review of the current geographic distribution of and debate surrounding electronic cigarette clean air regulations in the United States". Health & Place. 31: 75–82. ISSN 1353-8292. PMC 4305454 . PMID 25463920. doi:10.1016/j.healthplace.2014.11.003.
- ^ "E-cigarettes to be stubbed out for under-18s". BBC News. 26 January 2014.
- ^ a b c "The Facts on the FDA's New Tobacco Rule". US Department of Health and Human Services. US Food and Drug Administration. 7 August 2016.
- ^ "Retailer Overview of FDA Regulations for Selling Tobacco Products". US Department of Health and Human Services. US Food and Drug Administration. 8 August 2016.
- ^ Eric Lipton (2 September 2016). "A Lobbyist Wrote the Bill. Will the Tobacco Industry Win Its E-Cigarette Fight?". The New York Times.
- ^ Gray, Eliza (27 February 2014). "Europe Sets New Rules for E-Cigs While the U.S. Drags Its Feet". Time (magazine).
- ^ "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. US Food and Drug Administration. 79 (80): 23142–23207. 25 April 2014.
- ^ Sabrina Tavernise (24 April 2014). "F.D.A. Will Propose New Regulations for E-Cigarettes". The New York Times.
- ^ National Conference of State Legislatures (5 May 2016). "Alternative Nicotine Products Electronic Cigarettes". National Conference of State Legislatures.
- ^ Cervellin, Gianfranco; Borghi, Loris; Mattiuzzi, Camilla; Meschi, Tiziana; Favaloro, Emmanuel; Lippi, Giuseppe (2013). "E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism". Seminars in Thrombosis and Hemostasis. 40 (01): 060–065. ISSN 0094-6176. PMID 24343348. doi:10.1055/s-0033-1363468.
- ^ Maloney, Erin K.; Cappella, Joseph N. (2015). "Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers?". Health Communication. 31: 1–10. ISSN 1041-0236. PMID 25758192. doi:10.1080/10410236.2014.993496.
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 why are kids actually using these products.
Why, why are they so into them, and the health dangers that, the health risks associated with E-cigarettes.
Um, and we're also going to talk about how the tobacco industry targets kids with these products, and then mention what you can do.
And we have an excellent line-up of speakers.
Kris Minard: All right.
So Nicole mentioned this is mostly for adults right now, although it's very important kids know about this too.
But this particular um, presentation is, is geared for you.
We'll talk about Montana youth trends and um, let you know more about what electronic cigarettes are, their appeal to youth and then what's actually in the E Juice.
Every time we give a presentation we have to remind people we're talking about tobacco products and tobacco is still the leading cause of preventable death in the United States, killing almost a half a million people every year, which is the same as three fully-loaded 747's crashing every day, with no survivors.
So, if something like that happened, I think people would really take up, take notice and we, we need to remember we still have a lot of, we've done some great work on tobacco, but we have a long way to go.
So, as far as Montana youth trends go, we have great data, stretching back into the early 90's from the Montana Youth Risk Behavior Survey.
Our high school students are asked every other year, um, about their risky behaviors and how much they participate in them.
And, as you can see, these are the kids who say they have every tried smoking cigarettes, even one or two puffs.
We've got a nice trend down from the 90's.
We're at about 39% of our high school students who say they've even tried using tobacco.
These are the students we call current users.
The CDC says if a student responds that they've smoked a cigarette in the last 30 days, then we're going to call them current users.
A lot of people might think that Montana has more smokers on average than the rest of the country, but our, our students have really much um, kept up with the national average all through these last 20+ years.
However, you can see in 2015, 13% of our high school students say they smoked cigarettes and only 11% um, in the nation said they are, so we are above the national average there.
Then we've got these guys, these fruity-flavored, cheap, inexpensive um, cigars, cigarillos, that are kids have, have noticed and, and started using.
We are well above the national average at about 13% compared to 10.
Still a little bit of a decline, but nothing like, you know, it hasn't been as high as the cigarette use, but it's right at 12.
6%, which is pretty, I mean, they're both basically 13%.
Here's where we stand out.
Our smokeless tobacco.
Still 12% of our high school students say they use smokeless, um, snoose, chew, and ah, compared to the national average of 7.
3%, so our high school boys are huge users.
One in five of our high school boys report using smokeless tobacco, fourth highest prevalence of use in the country.
Our girls also have the fourth highest prevalence of use, but it's at a much lower um, prevalence, 4.
So here are all three of the traditional tobacco products.
You can see they're all at about the same level in 2015.
So now we have these guys, these electronic cigarettes.
Well, they all basically deliver nicotine.
There are a very few that don't have some of the E Juice, has zero nicotine in it, but by far most deliver nicotine and they almost all have lithium.
Well, I don't know any that don't have a lithium battery.
They look like lots of different things.
Some look like cigarettes.
Some look like marking pens.
The one on the right, I say kind of looks like a mini lunar lander, and they're just constantly changing.
These things are evolving practically daily.
We also have um, electronic cigarettes we call mods that, these are the products that people typically drip the E-Juice into and they create the great big huge, we say vapor and vaping, but it's really not a vapor, it's an aerosol.
There are tiny particles of metals and, and it's actually an aerosol.
You can see someone even ingeniously made a E-cigarette out of a Coke can.
But they all basically have a mouth piece and someplace to put the E-Juice, whether it's already contained and in a cartomizer or if it's a tank that you have to fill, or if it's an atomizer that you drip onto a cotton swab with E-Juice.
Then they have the heating element, which is the atomizer which heats up, so there's no combustion as with cigarettes.
There's nothing burning.
It just heats up it and creates this, this aerosol in the lithium battery.
Here's a video that NJOY has for anybody to watch on the Internet about how to vape.
(Video) This is NJOY's vape pen.
You picked it up off the shelf or got it in the mail, but it might be intimidating.
We're here to help.
If you're ready to vape watch on.
Part One: Assembling the Vape Pen.
First, you're going to need a bottle of E Liquid, like this.
You can buy NJOY E Liquid wherever you purchased your vape pen.
Next, make sure the battery is detached from the tank.
Don't try to fill the tank with E Liquid when it's attached to the battery.
Unscrew the mouthpiece from the tank.
Open your E Liquid.
NJOY E Liquids are in bottles with child resistant caps.
So to open it, you'll need to push down on the cap as you turn it.
You don't want E Liquid in the center tube.
So when you fill your tank, tilt it and drip the E Liquid down the side.
You can check the milliliter amount by the markings on the side of the tank.
Remember to keep E Liquid away from your skin.
If you happen to get some E Liquid on your hands, make sure to wash them immediately.
We also recommend that you have different tanks for different flavors of E Liquid and that you discard any tank after about two weeks of regular use, depending on how you vape.
Changing your tank will assure that your vapor always tastes great.
Once you fill the tank, screw the mouthpiece back on.
Make sure the mouthpiece is on tight, then screw the tank on to the battery piece.
Now you're ready to vape.
Part Two: How to Vape.
Your pen comes activated right out of the box.
To deactivate your vape or to reactivate it, quickly press the button five times in a row like this.
The LED light flashes five times when your vape pen changes state.
When your vape is activated, put your lips to the mouthpiece.
Inhale as you press the button, and just like that you're vaping.
Part Three: Charging.
The LED light will flash 10 times during use when you need to charge your vape pen.
To charge, simply unscrew the battery from the tank and into the USB charger.
To preserve the battery, don't charge it in a place that's too hot or too cold.
You'll know it's charged when the LED light goes off.
Kris Minard: Anything, time for a little audience interaction.
Anything kind of catch you off guard on, on that one? Anything kind of noticeable? __: Wash your hands.
KM: (Laughter) If you get any of this E Juice on your hands, wash them immediately.
It's okay to inhale it into your lungs, but by golly, if you get it on your hands, wash it off.
Well, nicotine absorbs through everything and um, Dr.
Shepard will talk to us more about the effects of nicotine.
All right, um, gimmicks, there are lots of gimmicks.
The industry, the tobacco industry has had gimmicks for years.
Coupons and products, give aways and things like this, and make no mistake, the tobacco industry is invested in electronic cigarettes.
Yes, there are mom and pop vape shops, but RJ Reynolds, Phillip Morris, Lorillard are all into, into these products.
blu is one that you may have seen ads for on T.
These are what they call the starter kits, and this particular thing costs about $75.
00 a couple of years ago.
I don't know what they cost now.
I would think that the price has gone down.
They look like a cigarette.
They charge right in these cases and their gimmick is each case has a little wireless transistor radio in it, a radio wave, that if you turn this on, this is, this it'll, this is what it will do.
If you're within 50 feet of another person who has one of these.
So they want you to know who's around, who can you go buddy up with, turn it into a social experience again, and um, find somebody, you know, there's somebody around who's using this.
Let's find out who they are.
They also do this if they're within 50 feet of a place that sells the refill cartridges.
So, that's their, that's their gimmick on, on these.
The I Phone case.
It's all set up.
It's got it's own battery and ah, I think this is for ah, I'm not sure, I think it was an I Phone 5, but it's got a mouthpiece.
You can screw your own mouthpiece into the top and, and vape away.
They want to appeal to the environmentally conscious folks.
Our landfills are being filled by these batteries, these empty cartridges.
You know, a lot of really bad toxins and, and pollutants.
So they say, send us your old products and for every 50 old cartridges or old lithium batteries, whatever you send us, we'll give you so many points to buy our products.
So it never ends.
Ah, this woman is going to show you how to use blu and a couple of the, of the other products.
(Video) Um, and this is a blu disposable.
We're going to pull the little seal off of here.
Pull the little rubber cap off and puff.
That's it, nice and simple.
Now the blu starter kit has um, two batteries, five cartomizers and a charger.
These are re-changeable.
Um, this same concept.
Screw the closed cartomizer.
Everything you need is mixed up in here already.
Screw it on and again puff.
Nice and simple.
Another company we carry Smoke Stick, same, same principle.
We have a disposable.
You have an E, the starter kit.
Again, screw it on.
That, as you can tell, is a little bit more vapor than the blu gave me.
Kris Minard: So she had a lot of quick hits of nicotine right there and you can tell she kind of liked that Smoke Stick brand, because it created a little bit more, more vapor.
Um, we'll talk a little bit about these mods.
Um, the people build these themselves, and you can learn all about them on the Internet.
There are people who have their own YouTube channels that show you how to create these things, and they take great pride in creating the coils, and how many, how many turns and twists you have in them, um, relative to how many ohms it's going to produce, and you want to heat it up just.
It's all supposed to be red when it heats up and you put the cotton wick between it and that's what you pour the E Juice onto.
This is an RDA, re-build able dripping atomizer, and this is a mod that has fully computerized.
This whole set costs about $140.
00 here locally.
The battery is another $80.
I did not purchase it, and you can set it to all sorts of different levels to decide how hot you want it to get, how much vapor your, how much aerosol you want to create, and, um, all these little buttons help you.
We'll just pass this stuff around so you all can, can look at it.
There's a great tobacco prevention specialist out, out east who told me, she likes to put things in pencil kits and pass them around and see if people can figure out what's really a pencil and a marker, and what's really a, an E-cigarette, and I said that is a great idea.
So I copied her and it's pretty impressive.
Take a look through this pencil kit, see if you can pick out the E-cigarettes.
This is the fellow who's got one of the YouTube stations or channels and he's got over four million views on, they call them clouds making this big huge cloud with a, with a mod.
So now let's talk about teen vaping and why, why our kids are so, so interested in them.
The 2015 Youth Risk Behavior for their first time asked the question, "Have you ever tried an electronic cigarette and in the last 30 days how many times have you used one?" And you can see by the description they couldn't just say an E-cigarette, they had to define it so that the kids would know what they're talking about, because they're called so many different things.
I mean now you might just hear the word vapes, um, but the responses in Montana really caught us off guard and we were alarmed.
Fifty-one percent of our high school students said they tried them compared to 45% in the rest of the country, which is also huge.
This is what the percentage of people, the high school students who have tried them, broken down by male and female, so not a big difference between the two.
Boys typically have riskier behavior than girls, but you can see it increases with grade level.
A, every year you have more kids using these products.
And granted by 12th grade, some people are 18.
There's no question.
It would not be illegal for them.
Another reason, as Nicole has pointed out, why it would be great to have 21 be the age for using tobacco.
There would be no question.
There are no 21 year olds in high school.
Not in Montana.
They don't fund them.
And this is a question of whether they're current users.
Have they used one in the last 30 days.
So 30% of our high school students said they were current users.
Almost one in three.
And here's that breakdown.
Same, same thing.
Pretty close to the same, but still more boys, and again the same kind of transition from nine through twelfth grade, increasing each, each grade level.
So here are the three traditional tobacco products and then the E-cigarettes in green.
It's kind of a visual deal that boy, twice as many kids, more than twice as many kids are using this product and are smoking.
So anybody who tells you, oh it's just the kids who are smokers who are using this product, that's not true, and this shows you that.
Here's a breakdown by groups.
Um, the state averages of cigarette smokers and vapers, um, on the left and then some of our middle schools actually take the very same Youth Risk Behavior Survey, so those that do have showed us that, wow, twice as many middle school students are vaping as are smoking.
NAR, our Native Americans on a reservation, so that is the only group who are smoking cigarettes is still higher than vaping, but, but not much.
NAU, our Native American's in an urban setting, big difference.
NPA, Non-Public Accredited schools.
A lot of your private religious schools, um, like Central in Butte, Central in Billings.
ALT, those are alternative schools.
That's where our risk takers are and we know that there are huge issues there, and we've got a few projects that we're working on, but boy we, we need to do a lot of work there.
SWD, our Students With Disabilities.
So they're attracting all, all users.
Yale had a great study a few years ago, where they asked 5,400 young people who did vape, what's cool about it? What do they think makes them cool? They were not surprised by the answer, the flavors.
We've all seen and heard, and you're going to hear more from Sara tonight about the flavors, but they were taken back by the fact that kids said we can do vape tricks with them.
So vape tricks.
We're going to show issue, show you a few videos from on-line about what they're doing with these products.
(Video) What's up guys.
We're here at Flawless Vape Shop in Anaheim Hills, California for the 8th Trick Qualified __________________________.
(Music) Ricky was sad.
He just won the 8th Trick Qualifier for the BC Cog Championship.
How do you feel? I'm stoked Still a little nervous? Yeah.
(Laughter) What did you do to prepare for this competition? I vape every day because I work in a vape shop, so.
What vape shop do you work at? Vaper Hub.
Would you like to thank any of your sponsors today? Of course.
Got to thank LindaLace, Good Vibes, Vape Socks, Native Wakes of course, you know.
Good Vibes is my sponsor too.
Good Vibes is awesome.
(Laughter) So before you go, ah, do a signature trick for us.
Kris Minard: Um, anything catch you off guard? Anything kind of impressed you with that? __: The sponsorships.
They have sponsors.
It's like NASCAR and these are young kids.
I mean, he, he was probably 18 or 20.
To me he looked like he was 16 or so, but he said he vaped every day.
I mean, what is he doing to his lungs.
You have to practice a lot to, ah, when you see the next ones you'll, you'll be impressed.
(Video) Kris Minard: I just wanted to show you that girls are doing this as we know.
How'd you like to be the little brother pushed through the aerosol there? The last one is the, oh __: ________________ Is there an odor to it? Kris Minard: There is a slight odor to it, but that's a really good question because someone asked last night, are they using marijuana in these things? And they are, they are.
__: Something like for the feel um, my parents said on the clothing Kris Minard: Oh, can't smell the clothing, right.
Definitely not like tobacco.
There, there is an odor, but the thing about marijuana, is if they are using marijuana, there is no distinctive marijuana odor with these, so someone could be vaping pot right in front of you, um, and you wouldn't know it.
So, but, but, they say there is not much of an odor with these, but I have smelled bubble gum.
I have smelled some of the flavors, when we have done some experiments with, with bottles.
Um, oh yeah, this, this guy, I think this is the one that use.
Oh, you'll want to go back and then that one is a video.
This guy is a real professional.
(Video) Kris Minard: So, you can see.
There's a challenge to them.
There's a competition.
Um, this guy won $10,000, making as big of a cloud as he could possibly could.
So, there are competitions all around the country.
I've not heard of any in Montana, but you know how we are, a little bit behind other states sometimes on things.
We'll hope, we'll hope that we don't get any here, but there's money, there's challenge and kids get good at it.
They take pride in it and who knows what they're doing to their lungs.
So, we often hear well it's just a harmless water vaper.
Well, it's really not.
In fact, there isn't water in these things.
The three main ingredients are propylene glycol, which is something that we use in the theatre in fog machines, and it's generally recognized as safe as an edible, um, chemical.
But that doesn't mean that it's safe for our, for our lungs.
You know, eating something and inhaling something are totally different.
I often say it's okay to eat a peanut, but if you inhale a peanut, you're in trouble.
The flavorings are another thing that's typically in, in the E Juice and nicotine.
Um, and these have not been regulated by the FDA, so some have been found to contain all sorts of carcinogens as well as other toxic chemicals.
Um, the carcinogens on the left, Acetaldehyde, Benzene, Formaldehyde is created as the E-cigarette heats up and, and, so it's actually the heating of the E Juice that creates the Formaldehyde.
Nickel, Nitrosamines, um, and then other toxins, other irritants.
A Diacetyl is an ingredient that has added to the flavorings to help make the flavorings work better.
And you may have heard of popcorn lung.
People who were working in microwave popcorn factories were getting this irreversible lung disease, and they finally figured out it was from the Diacetyl.
Well, Diacetyl is in a lot of E Juice.
I have, I always say if you have to dress like this to work with this product and develop this product in a hazemat suit, then why on earth would anybody want to be putting it into their lungs? Congress did pass a Child Nicotine Prevention Act because a teaspoon can kill a child.
In fact, there was a young toddler who died just before Christmas a couple of years ago.
He got into his parent's E Juice, so, um, now they do have to have child-resistant tops.
Poison Control Center calls have grown exponentially.
In 2014 they increased from one a month to 215 a month for exposure to, to nicotine.
These, this is a little bit deceiving because the 2015 and 2016 data isn't complete on this.
I've been looking for better, updated charts, but, um, it's been a major increase for Poison Center Control calls.
And then you also heard about these exploding lithium batteries.
Um, the industry will tell you, oh it's user error.
You know, it's always user error, but I read an article about a man who opened a package and it blew up.
You know, he wasn't even using them.
We have a, had a young student in Missoula who was vaping and ended up losing four teeth and I really, I mean that was a very traumatic experience.
He had a really hard time getting back to school.
I mean, you can imagine.
It caused a fire on the couch he was sitting on.
So, not good.
This is an example.
Watch the guy standing at the counter on the right.
(Video) Kris Minard: Huge vap, you know plume of, of aerosol and he had to take off his pants and you, you saw the burns ahead of time.
So that's the end of my presentation and we have an, um, question and answer session.
So if you have some questions, we'll do that at, at the very end.
But thanks a lot for coming and thanks for listening, and if I can help you in any way, let me know.
Kathy Rogers: Research suggests that compared to adults, teens value reward more than consequence.
And we kind of all know that, but that is really an integral part of brain development in adolescents.
It is part of what gets them to grow up and leave home.
To go on the adventure of leaving the security of a household where somebody feeds them and clothes them, and takes care of their needs, and goes out to where they're going to have to figure it out.
And so it's, it's an important part of development, but it is also is what makes them take the risks that they do.
Brain development takes a long time, sort of from age 12 to age 25.
And so at 18 and 19, when these kids legally can do a lot of things, they still don't have a very mature brain.
They think they do and if you think back, you thought you did.
And then you got a little older and you realized your parents were not nearly as stupid as you thought they were.
And we hear that said all the time, but it really is true and there's no way to explain it as we grow up.
You can say it to your kids and they nod and think you're full of it, but it's really the truth.
So it, brain maturation moves in really slow waves.
It starts at the base of your brain and kind of moves forward in very basic functions, so it starts with your vision, what you see, and then movement, and then fundamentally how you process things.
The more complicated executive functions.
So this front part of your brain, which is the last part that really puts together, if I jump off of this very tall building, I may break my legs.
And the other part of it says, yeah, but won't it be really cool if I don't.
That part takes a long time to come together, and so there's all these different parts of the brain that you're going to hear talked about as, as more of the issues of brain development go on.
You're going to hear them talk about your hippocampus, which is part of your memory.
The frontal areas set goals.
They weigh agendas and risk and that frontal part is really important.
Um, head injuries, a lot of frontal injuries impact how well we do our executive functions and this is sort of a side comment, but the whole business of concussion relates to what happens when you're constantly impacting that frontal area, which becomes your consequence setting goals, agenda, risk assessment area.
Um, so ultimately development allows us to balance our impulse and desire and our self interest and put that together with ethics and rules, and to put all of that together.
But it takes time and you can have a kid who will say, I know I shouldn't, but they still will until they get on the other side of that fence.
If you think of teen decision making like an equation, where consequences aren't given the weight they should be, rewards weigh more heavily than they should, and where being friends throws the equation off any more.
So that plastic part of your brain really looks at thrill seeking, risk taking, and I don't have a graph to show you, but when you look at higher risk and lower risk and then age, the ones who enjoy it the most are 16 to 17 year olds.
They just, that high risk is like a really good reward, and it's interesting because at 18 and 21 it starts to drop, but it doesn't get down to a level less than when you're 10 years old till you're 26 years old.
So, there's a long time where that is all really important.
Most long-term drug use, alcohol, tobacco, nicotine, starts in adolescence.
And we all recognize that.
Teens do know they're mortal.
They can estimate risk, often over-estimating risk.
They simply value the reward so much more heavily and the more risk they take, if the reward is good, is perceived as a better payout.
And what helps them add to the risk? Doing something with their friends.
So when you look at kids who are learning to drive, there's lots of good valid studies that show.
If you put a kid in a car with an adult, their parent, they will drive beautifully.
They take Driver's Ed, they do really well, and as long as they are in the car with the adult, they're great.
You put one person in the car their age and all of a sudden they run through the red light.
You put two or three kids in the car with them and suddenly it's what can we do? Where can we race? Why? Because there's this huge reward of doing these things, taking these risks with their friends.
So, when you're looking at kids related to cigarette smoking, vaping, it's the same thing.
And so one of the key questions I always ask kids when I'm interviewing them, is do any of your friends vape? Because if you ask them directly, you may or may not get a straight answer, but they don't have any problem telling you if their friends do.
And that's a really good way to kind of come in through the back door when you want to find out what's going on.
Because if their friends are vaping, you can bet that for them it's a greater opportunity, even if they think they're only going to do it once.
So, what their friends do does make a really big difference.
Now, this time of taking all these risks is important.
They need to do this.
It doesn't make them obnoxious, although sometimes it feels like it does when you're the parent.
Um, but that's partly again what gets them to learn how to be independent and on their own.
So adolescence brings a peak in brain sensitivity to dopamine, which is a neurotransmitter, that kind of primes you for reward.
And it fires off the reward circuits.
So anything that improves and effects dopamine is something that they like, and nicotine will effect that as does marijuana and so these sort of spark that area and kids go, oh that felt good.
And feeling good is something you want to do.
Believe it or not, texting fires off that part of your brain, which is why those ridiculous texts of what'ch doing.
Where're you going to be? Not sure.
And yet they're just addicted to it.
They literally fire off that little bit of dopamine over and over again, which is a little pleasure center.
Um, for those of you are old enough, if you remember what it was like to get a letter in the mail and you would wait for the mailman to come.
It's the same thing.
It just didn't happen every five seconds.
So that's part of the difficulty and again, anything that will allow them to get there.
Teen brains, neuro networks are being pruned, and so they're still in that developmental phase.
And it's really interesting, teens prefer teens.
So the things you say do make a difference, but they search out their friends and that's, those people are their investment in the future.
They're not going to spend their life living with you.
You guys are their mentors/directors, but they know you and you're not exciting any more.
Their friends are exciting and that's where they want to be.
So again, who they spend time with and we're back to, what makes me feel good? What's exciting? Um, you guys have the statistics and will probably go over them, so I'm not going to take about the percentages of kids who are using E-cigarettes.
But what I will tell you is, for child, for kids, it's not a reduction of harm.
They use E-cigarettes and they talk about it for adults as a reduction of harm, getting them off of cigarettes.
It doesn't do that for kids.
It becomes the gateway.
It addicts them to nicotine, and we know from both human studies and mouse models, that at the developmental point in your brain that you are when you're a teen, your brain is more plastic and nicodine, nicotine is far more addicting.
We don't know why.
We just know it is.
And it's that developmental phase.
We also know that the various products like nicotine and marijuana at that stage long term will affect brain function.
So when you were talking about the different products that are in there.
So nicotine poisoning, what does it look like? Vomiting, sweating, dizziness, increased heart rate, lethargy, seizures, breathing difficulty, um, it's a neural stimulant at low doses, but at high doses it's a depressant, and it really gets them into trouble.
A couple of things that you need to know and that parents should share with each other; anti smoking actions by parents are a strong predictor of non-smoking in teens.
Anti tobacco opinions, anti vaping opinions and discussions with parents are factors that protect kids against tobacco, even if a parents smokes.
So even if you're a parent who does smoke, the very fact that you say no, makes a huge difference.
The bottom line is, is that you want to make the risk and the reward enough like the reward for not doing this, greater than the reward for doing it, and because nicotine's so addicting, you've got to find ways to sort of them, it's like the toddler thing.
You have to distract them over here.
You keep them busy with other things that are rewarding and fun for them whether it's school or trips with friends that you get to help plan and organize.
But it's pretty basic and it's pretty simple and I can go through all of the neurochemistry and, and all of the brain development doesn't mean anything.
The bottom line is, they like what feels good and what you have to do is find things that make them feel better and make it new and exciting and just sort of distract them until their brain gets to that point and then you also make it clear that this isn't something that you want them to do.
But that's not what you harp on all the time.
You just do the distraction.
That's my line.
Robert Shepard: Um, all right.
I entitled this Nicotine, Safe or Dangerous because I was up at the Legislature trying to get them to increase the tobacco tax, the bill supported by the Governor and Cancer Society and Heart Association, to increase the tobacco tax and ah, they were going to include E-cigarettes on that increase, and actually I was flabbergasted, is the best way to put it, at some of the claims that were made by the E-cigarette proponents about the safety of E-cigarettes and the safety of nicotine.
So, since nicotine is the predominant ingredient in all of the E-cigarette liquids that are set out, I wanted to talk a little bit tonight about nicotine.
Now, before we get to there, we can talk about tobacco and several different oranis, several different kind of categories.
Obviously, there's combustible tobacco, cigarettes, cigars, pipes, and those, those things have a completely different of chemistry.
After all, they're, they're burning, they're burning at a very low temperature really, so they create all kinds of chemicals that get into the air, and that creates all the second-hand smoke and other stuff which is the primary motivation for second-hand smoke laws.
Ah, but we're not going to really talk about combustible tobacco tonight.
You've got your various forms of spit tobacco.
I like to refer to it as spit tobacco to make sure that it's overly glamorized.
Um, but in any case, you've got the various forms of spit tobacco and they also have their own set of chemicals, but they're not heated.
They have chemicals that also that occur a lot during the curing process from the way the tobacco industry cures it, which creates a lot of extra stuff in the, in the leaf beyond just the tobacco plant.
And then lastly we have the E-cigarettes which you've heard about it, and they're not really combustible, but they're not exactly like ah, non-combustible chewing tobacco products because they are heated, and that also has a potential to create different chemicals.
Um, so, and I want to focus a little bit on nicotine now because, 90, somewhere around 97, 99% of all E-cigarette capsules and liquids that are sold are sold with nicotine in them.
So they talk about all the other stuff that goes on, but it really has to do with the nicotine.
So, is nicotine safe? Is it beneficial? Is it addictive? So let's kind of explore some of that.
First of all, there, the way the body works is most of the cells in our body have little tiny receptors on them.
You can consider the receptive would be a lock.
A molecule, a chemical will come by and insert itself into that lock and that creates, causes the cell to do something.
That's the way hormones work, whether they're thyroid hormones or testosterone or estrogen or any of the other, you know, cortisone, any of the other, ah, hormones around the body all work by attaching to a receptor on a cell.
And each cell will have tens of thousands of receptors on it.
It's hard to believe something so small can have that many receptors and there will be dozens of different kinds of receptors on every cell.
Some of these receptors then in the body are triggered by nicotine.
That's how nicotine does what it does.
So nicotine will glom on to, you know, insert itself as a key into that lock and then tell the cell to do something.
And they're really high in concentration in the brain, which should come as no surprise.
Secondly, there are a lot in the lungs and there's, one important thing is that there are an awful lot in the lining of the arteries, what we call the endothelium.
That's a lining of the arteries, incredibly important for the arteries being able to dilate and contract, and also important because when the lining gets torn or injured, cholesterol then leaks into the wall of the artery and that begins the plaque formation, ah, of heart disease.
And nicotine has profound impacts on that.
So there are impacts on the way the cell functions.
If you're looking at an embryo that's developing, these receptors will trigger development in different ways and consequently their impacts on the way the body develops as a result of that.
Ah, and this particularly in the brain impairs the development of neurons.
So as we are adding neurons as the fetus is growing it's brain, it's going to end up with fewer neurons in the brain because of nicotine exposure during pregnancy.
Now, how do we know all this? Well, there are lots of different ways that we know this.
First of all, there's studies of animals that we can, we particularly use a lot of rats and mice in these kinds of studies.
They're small, they grow quickly and we can study them a lot faster.
We also use primates, various kinds of monkeys and, and stuff in that.
Also we can know because we can look at systems in humans that are really vulnerable.
Systems like in pregnancy, where we have a growing, the fetus and the, that system is very very vulnerable to affects, so we can look for these sorts of things, ah, in that area.
We can also just grow the cells in a lab in a cell culture and then expose them to these products and see what impact it has on individual cells.
And there are not just multiple studies, but we're talking about thousands of studies about the impact of nicotine studied through all these different systems.
Now, the nicotine system in the brain, the nicotine receptors in the brain, have impacts on memory, how well we think, how well we focus our attention, and also on emotional responses.
Now, some people think that in adults, I'm going to say that again, in adults, nicotine might slightly enhance our memory, our ability to think and our ability to focus.
There are no good human studies that prove that that's the case.
When I was up at the state they were talking about the study in Discover Magazine, I like Discover Magazine.
I read it cover to cover every month when it comes out, and there was this highly speculative article about the im, the positive impact nicotine might have on the adult brain.
And it says right in the center of the article, there are no studies that show that this is true.
And yet, this, this journalist was making this great case for how wonderful nicotine was going to be on our brains.
Well, it ain't true.
Well, at least it's not been proven true yet.
However, when we are talking about a developing brain, again we're talking about fetuses, infants, toddlers, and we're also talking about adolescents as we hit, hit that period of time when that judgment part of our brain between 15 and 25, when we develop judgment in our frontal cortex, that presence of nicotine changes the way the brain develops, and that's not a good thing.
So there are fewer nerve cells, some of the nerve cells are damaged.
There are fewer connections between the nerve cells and there's all kind of changes in the brain chemistry.
Nicotine is a very powerful stimulant of the dopamine system.
Dopamine is our pleasure reward system.
When you get dopamine you feel good.
There are all kinds of things that give us dopamine.
Nicotine is one of them.
So, what about the fetus? Well, nicotine crosses the placenta.
There are more nicotine receptors in a developing brain because the body uses those receptors to guide the development, but when you add a bunch of nicotine to that and over-stimulate those receptors, you end up with some brain cells dying and some brain cells getting malformed and the number of some brain cells not forming the connections to other brain cells that they're supposed to have.
We know in human studies we haven't really been able to check this because for obvious ethical reasons, you're not going to take 1,000 women and say you get to take the nicotine and take another 1,000 women and say you don't get to take any nicotine, and see what happens to the baby.
Nobody is going to do a study like that.
But, we have seen what happens in smokeless tobacco from the nicotine.
We've done lots and lots of studies on animals to see how the brain develops in animals, and what we can see is there's a real strong correlation between the affects of nicotine and the effects we see on human studies that are using nicotine, in human subjects that are using nicotine as well.
So in other words, they're consistent with each other.
Now, let's talk about one other thing here for a second and that is, what do you do about nicotine in pregnancy and nicotine replacement? And how do you get women to quit? Well, first of all 40 women who are pregnant, 40% of women who are pregnancy find that to be a powerful motivator and they will in fact quit smoking.
An unstressingly amount of them will go back to smoking once the baby's born, which doesn't help the baby a whole lot either, but they will quit during pregnancy.
Nicotine replacement therapy has been something that medicine has used a long time to help people quit smoking, but both ACOG and the FDA say that's a last choice in pregnancy, because we just don't want to expose the fetus to nicotine.
Well, what about harm reduction.
The concept is here that perhaps if we do something that's less dangerous, there will be fewer people that are hurt by it.
So, if we move people from tobacco to pure nicotine like in an E-cigarette that that's going to be good for them.
I just want to point out that the lowest possible risk is from quitting nicotine all together.
At that point, you've reduced your risk to zero in terms of the nicotine.
So E-cigarette are counted as great because they're going to reduce the harm.
But what happens with the 40% of women who successfully quit smoking, instead switch to E-cigarettes and still get the nicotine? I would just suggest that that's not going to be helpful for their baby and this case the harm reduction isn't really going to be a harm reduction at all.
So, this is just theoretical again.
This is smokeless tobacco again, because we don't have studies on E-cigarettes yet, but several studies, and I've just given you some quotes from a couple of them, have looked at the impact and what we see is the impact on fetal exposure mirrors what we see in animals, including adverse behavioral outcome, such as attention deficit disorders, disruptive behavioral disorders and other things that we all struggle with in the school system today.
And, I'm not going to spend much time but I just do want to mention that nicotine has an impact.
The receptors alone decrease the number of lung cells along size and volume, the lungs become less elastic and impacts the lungs too.
Okay, are there any studies then on children with E-cigarettes? And the answer is no, not yet.
But we've looked at this and second-hand smoke a lot, and we know that children who are exposed to second-hand smoke at the home, in the home have more difficulty with reading and arithmatic comprehension.
Their school test scores are lower, ah, and, so we know that there are effects from, from that.
We aren't absolutely certain that's just the nicotine, but it's certainly consistent with pure nicotine research in animals.
There is also a concept called third-hand smoke and third-hand smoke is what's left after the second-hand smoke dissipates.
So you smoke a cigarette in a room, the smoker gets the primary smoke, everybody else in the room gets the second-hand smoke that's just out in the room.
When the smoking stops, what happens to the smoke? Well, it goes some place.
Some of it's absorbed onto the walls, onto the ceiling.
Cigarette smoke is composed of lots and lots of little particles.
These particles fall like rain onto the carpeting.
When you have a little rug rat rolling around and anybody who's ever had an adorable six-month-old crawling around, of course, they never put their hand in their mouth, and they never touch anything on the floor.
And you can show that these kids have nicotine levels that are equal to our, almost equal to the kids that are exposed to second-hand smoke.
So when you move into an apartment where somebody has been smoking in that, that out gassing continues for six months to a year.
Everything that was absorbed onto the walls starts coming out again when the smoking stops.
Everything that's in the carpeting gets picked up and blown again through the air when you vacuum.
And if you're down on the carpeting, ah, the five-second rule doesn't apply because it's going to be full of nicotine.
Okay, last third-hand smoke.
What we know from that that's pure nicotine in a lot of cases and that sort of gives us a good clue that those sorts of things are still happening with nicotine.
And as mentioned earlier, ah, children get into these E-cigarette cartridges and 40% of the tobacco related calls and Poison Control Centers are related to nicotine.
So, and this is really alarming.
Now we're seeing this incredible increase in E-cigarette use in adolescents.
Adolescence is a time when higher cognitive functioning begins.
Nicotine impairs that.
Development of the prefrontal cortex, which is this area, this part of the brain, which is where our judgment comes in.
Um, and the receptors are a major influence on how this executive kind of control mechanism that we all have to control our impulses, ah, begin to occur.
This animal studies again show that nicotine has a major impact on the way that these, the brain develops at this point and adolescents are going to be really a problem with this.
And if we go back and think about just how many percentage of kids are using E-cigarettes, we've got a real cause for alarm here now.
Now, adolescents are also much more likely to become addicted to any substance they use.
DeFrance, a guy in Boston who's been studying this for a long time, just shows that nicotine really is the true gateway drug people become addicted to nicotine and that leads to experimentation with other, ah, ah, drugs.
He shows that an adolescence, meaning say from 14 to 18, smoking one cigarette a week for six weeks is enough to get 50% of the kids that are addicted, are addicted to it at that.
One cigarette a week for six weeks and 50% of kids become addicted.
But the really scary thing and the really kind of interesting thing is that about 5% of kids will literally become addicted on their first cigarette.
And he, he says you can pick those kids out because they'll tell you when they had that cigarette, it was the greatest sensation they'd ever felt.
For that moment, they felt better than they'd ever felt in their life.
And those kids are the ones that are going to get hooked really on just one cigarette.
Now, the other thing is is that we've now follow, had an opportunity, cigarettes have been out long enough to follow these kids over time.
And kids who use E-cigarettes but don't smoke and have never smoked are three to five times more likely to start smoking than kids who have never used E-cigarettes.
So they clearly are an initiator for the use of cigarettes as a whole.
So, well, doesn't that mean that this is addictive? I couldn't believe it.
They actually tried to make the claim, the state, the Legislature, that nicotine was not addictive.
God, I so wanted one of the, the Representatives to ask me a question about that, Senators, I guess it was, ask me a question about that.
I was just absolutely flabbergasted that anybody would make that claim.
But, let's go back and look at it.
I had the opportunity once to share the stage with Victor DeNoble.
He was one of the guys that used to work for the tobacco industry.
They hired him in the 1970's to produce a heart-safe cigarette.
Um, he says he was successful at it, but since Phillip Morris never really brought the cigarette out, we don't know if he was successful or not.
But, be that as it may.
He started studying.
He had to get the rats addicted to nicotine and he was using pure nicotine I.
and was just a steady drip.
He was having a little trouble with rats would kind of like it but they didn't seem to be very crazy about it.
And he was sitting in the cafeteria watching people smoke one day and he realized that people smoke intermittently.
They take a puff, they put the cigarette down.
They take a puff, put the cigarette down.
So he went back to the lab and changed his pump for the rats, so that it pulsed the nicotine and those rats went crazy for nicotine.
That pulsing creates a surge of dopamine, a drop off, a surge of dopamine and a drop off, and that leads to powerful addiction.
There are now dozens and dozens, if not hundreds of studies showing that nicotine is in fact addictive.
So, that, we ought to be able to put that aside.
Are there other substances in tobacco that also produce physical dependence? Certainly.
But it's nicotine that the tobacco industry manipulates.
One of those things that was in cigarettes is formaldehyde.
Formaldehyde is also found in tobacco.
Formaldehyde's that really great smelling stuff that they used to put the, the frogs and the rats in in your biology class to preserve it.
You have to wear gloves when you use it because it's a carcinogen.
It also is mildly addictive.
That is, you actually get physically dependent on it.
I can't imagine something that would be worse than that.
However, it's real value to the tobacco industry is that formaldehyde increases the addictiveness of nicotine.
So the more formaldehyde there is in a cigarette, the same amount of nicotine is more likely to make you addicted.
So, ammonium does the same thing and there's a fair amount of ammonium in cigarettes.
I haven't seen any reports about ammonium in E-cigarettes.
So the tobacco industry deliberately manipulates the content of other chemicals in the cigarettes to potentiate the nicotine and make it more addictive.
They wouldn't be doing that if nicotine weren't addictive in the first place.
They'd be manipulating whatever it is that really is addictive.
They're manipulating the nicotine.
Okay, so what about addiction.
Well, if you dabble with alcohol, about one out of every 10 people is going to become an alcoholic.
But hey, if you dabble with cocaine, about one out of every six people is going to get addicted to cocaine.
Okay, now take a second and just think about what the addictive potential is of nicotine.
And the answer is, that one out of every two is going to get hooked in the long run.
As I said half of them will be hooked in adolescences, one cigarette a week for six weeks, but you keep going and at least 50% of people are going to get hooked.
This isn't scientifically proven, I should say.
This is the opinion of the addiction experts at John Hopkins.
So I would take that as a reasonable effect.
Okay, what about quitting? Well, nicotine replacement, you may have already heard about that's the gum, the patch.
They make an inhaler now, a nasal squirter.
Different ways of replacing nicotine.
They work about 5% of the time.
The inhaler works a little bit better than that.
But the gum and the patch will help about 5% of people who quit smoking.
Some antidepressants have been tried and they'll help about 10% of people who quit smoking.
Chantix, which is the, another smoking aid will help about 20 % of people who quit smoking.
Counseling is in the 15-20% range and counseling and medication get up to 30%, sometimes 35%, in that range.
Ah, to put that in perspective, when a doctor tells a patient to quit, about 2% of people will quit.
So, I always used to say I'll take my 2%, but I'm not very effective at getting people to quit smoking, just by telling people to quit smoking.
I have to do something else.
So, what about E-cigarettes? Well, first of all let's point out that E-cigarettes are not FDA approved as a quit aid.
Let's also point out that no company has applied to the FDA to present data to say that they're a quit aid.
So making a claim that they're a quit aid is completely bogus from a scientific point of view or a regulatory point of view.
Now, you, it is important that you do long-term followup when you do these kinds of studies.
Your quit rate in 30 days is always going to be better than your quit rate at a year, always.
Um, survey with some other, early studies did that suggest that E-cigarettes could be a reasonable help in quitting, helping people quit smoking.
The trouble was there were methodological problems.
They didn't follow them long enough.
They didn't check to see that they were really quitting exactly.
They didn't double-check them.
Some of the questions that, were whether or not they still smoking.
So they didn't really get rid of the dual use group.
So, they kept working at the studies and the studies kept getting better and they eliminated the methodological problems and as they did, they began to see that there really was no impact.
That is, people using E-cigarettes did not quit at a greater rate.
And recently they did what is called a Meta-Analysis, which is one way of combining a whole bunch of different studies into a much larger number, so you get bigger numbers and you get better statistical probabilities because you've got more people.
And when they do that, they showed that E-cigarette users were actually 28% less likely to quit smoking than people who used other quit aids.
So, another thing is, is that 80% of E-cigarette users in several surveys, but somewhere between 60 and 80% also use traditional cigarettes.
That is, that they're dual users.
So they're really not getting the benefit of cigarette cessation anyway.
So, ah, first of all we can build a little bit.
We've been researching cigarettes for more than 40 years.
And we have learned a lot about how cigarettes cause disease, whether it's cancer, whether it's heart disease.
As I mentioned, some of the effects of the brain, but we're still really, research into pure E-cigarettes.
Still, there are some effects that have been shown.
So for example, at heart disease, one of the things you need to be able to do is to make the arteries open up, so when you're heart's stressed, your coronary arteries have to get larger so you can pump more blood to your heart too, and the heart can work harder.
You can't do that effectively if you've had nicotine in your system, because nicotine, wants the ability of an artery to open up.
It can't open it up.
It just stays stuck.
Now, you get under some stress and you can't get enough oxygen or blood going to the heart muscle, and that can cause a heart attack.
This is due to the adverse impact on the endothelium, and we know that nicotine actually kills endothelial cells.
When you give somebody nicotine and then filter their blood, you can find dead endothelial cells floating around their blood stream.
When the endothelium is damaged like that, it tears more easily just from the normal movement and then you start getting stuff from the blood stream into the artery wall, and that's how plaque forms.
Also, there are these things called platelets.
Platelets are little tiny cell particles and their function in the blood is to clump together, so when you get a cut, they clump and plug the end of the blood vessels like a cork in a bottle and stops the bleeding.
Which is why we tell people to take aspirin when they have a heart attack because aspirin tells the platelets don't clump, and we know people can get a heart attack because the blood literally clumps inside of the blood vessel, instead of when it's bleeding like it's supposed to, and that cork in a bottle can cause a heart attack because it stops the blood flowing through that artery into the heart.
We tell people to take an aspirin because it keeps the platelets from clumping together like that.
However, nicotine in the particles, particularly the particles which are in E-cigarettes, that's why you see the cloud of smoke.
Those particles tell the platelets to clump together faster so they make it worse.
Now, we actually do have one study that just came out in March of this year that showed people who used E-cigarettes had an increased risk of having a heart attack of 42% compared to people who didn't use the E-cigarettes.
So we now have one study.
That by the way is very consistent with the studies on second-hand smoke, which is about in the same ballpark.
So, harm reduction.
Well, my analogy is this.
You have a ten-story building, you jump off the building you really don't expect to survive.
I apologize, this has only nine stories if you count the roof.
I didn't have a ten-story building.
So my idea, my thought is, is, sure when you do E-cigarettes, you might be jumping out of the third floor instead of the tenth floor.
You're still likely to get hurt and you might survive.
That's harm reduction.
That's what they mean by harm reduction.
The best thing to do is to walk out on the ground floor because it's the safest way to get out of the building, not jumping.
Now, if the data on heart disease pans out the way I've outlined it, after all we only have a few studies and we're still working on this a lot, we only have to move that from the third to the fourth or fifth floor.
Okay, on my last slide and then I'll shut up, is that again, and this is a slide that Kris showed you earlier about this dramatic decrease in ah, of Montana of people using cigarettes.
But remember, I don't have, do I have a pointer on this thing? Oh yes, okay.
The, there's 30%, somewhere around here, is where the E-cigarette use is.
Now, stop and think about this.
Those kids are three to five times more likely to start smoking.
I don't know what's going to happen to this number, but with this dramatic increase in E-cigarette use, we may be seeing this bottom out and starting back up again.
Only the future will tell us that, but I'd be really alarmed at what we're seeing.
Sarah Shapiro: All right.
So, I'm Sara Shapiro, I work for Lewis and Clark Public Health and I'll be talking about the tobacco marketing, um, in Montana, specifically the point-of-sale marketing.
So each year 9.
6 billion dollars is spent on marketing tobacco.
That's 26 million dollars every day and that's over 1 million dollars an hour.
In Montana that's 30.
5 million dollars spent a year from big tobacco and 95% of that money is spent at the point-of-sale location.
So when I'm talking about point of sale, I'm talking about where we buy our milk.
Where we buy our soda.
Where we buy candy.
It's where tobacco is sold.
So that is at convenience stores, gas stations, pharmacies, etc.
So this also mainly what I'm talking about.
This is what you see when you're checking out of those places.
So you're being marketed to at all aspects of these locations, so this is the outside, the advertisements, the price discounts.
Inside you go look where the Slushies are, there's something about Marlboro.
By the ice cream you'll see it, and then you also see it near the drinks.
You see it on all angles.
No matter where you go you're going to see these advertisements.
Some price discounts right above where you're checking out.
And so I'm mainly going to talk about this power wall.
So this is where the majority of the tobacco products are located.
So when you go to check out you really can't miss it.
Raise your hand if you recognize this.
So big tobacco is targeting for specific groups.
They're targeting people who are using.
They want them to continue using the product.
People who quit, they want them to start using again.
Would be users, those are the social smokers, the every once in awhile, the when they're drinking smokers, and then youth, who is what I'll be talking about most of my presentation.
Nine out of ten tobacco users start before the age of 18 and once they start, most are hooked for a long time, or the rest of their life, and so they're trying to get these replacement smokers.
So I'll go over the tactics that are specific to big tobacco is specifically using to hook these populations.
The first is eye level is buy level so most of the tobacco products are in front of the counter are at about three feet, so that's definitely not my eye level.
It's a younger population's eye level and it's mixed in with the candy.
So they already know that kids are looking at the candy, looking at the bright colors and the flavors and ah, that is where they're putting these tobacco products, and so I'm talking a lot about cigarillos, the flavor chew, E-cigarettes as well.
So as you can see, it's at this young girl's eye level, mixed in with this gum.
So, the, the kid is at 45 inches and the poster is at 45 inches, the tobacco poster.
Another thing is flavors.
So E-cigarettes, cigarillos, they come in a million flavors.
There's bubble gum, fruit loops, strawberry, mango, root beer float.
So these are definitely flavors that are targeting the inner crowd that is looking for that candy already, and sometimes these are mixed in so they look like candy.
If you've seen the commercials recently, you can look them up and they look identical, and they also look identical because of the packaging.
A lot of these products have the really bright colored packaging, so it looks like candy.
Another tactic is price discounts, so younger populations tend to not have as much spare money.
So using discounts, coupons, buy one, get one free, um, helps it seem more affordable and seem like something they could try to hook people.
I'll read this quote.
It's "The industries extensive use of price-reducing promotions has led to higher rates of tobacco use among young people than would have occurred in the absence of these promotions.
" The U.
Surgeon General, 2012.
And so that's saying that these are working, that more people are using because of these price discounts.
So why are they going after youth? Is cause they want their replacement smokers.
So Phillip Morris, one of the main tobacco companies, has been noted saying "The ability to attract new smokers and develop them into a young adult franchise is key to brand development.
" So, they're older population is getting older, getting sick and they need to replace, they need to replace people who are going to use it for the rest of their lives.
So that is why they're going for youth.
Place is really important.
Can we raise our hands if you've been inside a gas station or convenience store in the last week.
So normally when I go to the gas station, I don't go inside any more.
I pay at the pump and I leave and I don't really go inside very often, but 70% of youth go into gas stations and convenience stores weekly.
So they're extremely vulnerable to this number, um, because of all the different advertisements.
They go during lunch to get candy.
They go on their walk home.
Um, it's kind of like a right of passage to be able to go to one of these places with your friends.
And so place is really important because of the amount of them in Helena alone and then Broadwater.
This is just our area and how many places you can see it and be victim to this advertising.
So adver, this pays off.
There's a reason that 30.
5 million dollars a year is spending in Montana.
So each day 3,300 youth under the age of 18 will try their first cigarette, 700 of these children will become regular smokers.
So it's a scary number.
Um, but it's showing that this advertising is working.
And again this is another graph showing that same thing.
It's showing how the green bars are showing the dollars spent on E-cigarette advertising and the line is showing the past 30 day great use among youth, and as you can see, as advertising goes up, so is the use among youth.
So this is just another graph showing that um, the amount of E-cigarette users is going up every year.
So this tobacco marketing is working and why we should be scared of it is because it normalizes the presence of tobacco products, meaning when youth go into these locations and they see how much tobacco is and where it is all over the place, it seems like more people are using it.
And when more people use it, the way to fit in.
So, it normalizes the idea of it.
It encourages youth to use tobacco and eventually get hooked.
It makes it harder for current users to quit.
You know they want to buy the milk, but they're seeing this tobacco product every time they try to check out.
It encourages people who quit tobacco to start using again.
So these are some pictures that I did from a recent scavenger hunt that I've been doing with the youth.
What I do is I take youth to these different locations and they have check marks and they have to check if they see products below three feet, what flavors they're seeing, what discounts are seen.
Can you see it from the road.
Things like that.
And so I'm able to work with youth to understand this and it tends to be empowering because they don't like being targeted.
You know, they want that independence and that freedom, and so they don't like how these companies are targeting them.
Um, I'm also doing presentations to multiple groups trying to get the word out because once you learn these tactics it's really hard to not notice them.
So that's one thing I encourage everyone here to do, is to go into these stores and notice them and realize them, and then tell your friends.
Tell your peers.
Tell the youth, um, to keep educating.
Nicole Aune: So, I'm just going to do a final wrap up here and kind of leave us with, so now what.
We've heard all these things.
What do we do next? What are our actions steps? So, just to talk a little bit about the, the laws that are in place now.
In January of 2016 Montana set a law that you have to be 18 in order to purchase E-cigarettes.
Before that anybody, any age, could go and get these.
You could be 7 years old and walk into a store and be able to buy an E-cigarette, which is just absolutely atrocious.
So at least now we do have that law in place.
That was set here in the state in January of 2016 and then the FDA came and set it, set a law in May of 2016 at the national level.
So now that's a national law that you have to be 18 in order to purchase these products.
Um, they are also not allowed to be sold in vending machines where kids can, where kids are present.
Um, they're not allowed to give out free samples.
And starting in May of 2018, um, if we get there with this administration, um, warning labels ah are, are going to be required.
And I thought that this, this is kind of interesting this warning label right here, because um, it, you'll hear as Dr.
Shepard said many times, you hear the E-cigarette industry saying, oh nicotine is, is actually good for you.
It's not harmful at all.
So, now you're being required to put a warning label on that explicitly states that nicotine is harmful and extremely addictive.
So, just putting that out there.
So then, we actually have some other laws here in, in Montana.
So we've had a few counties that have taken it upon themselves to include E-cigarettes in their local Clean Indoor Air Act protocols and actually Lewis and Clark County was the first county to do that.
So, yeah, Lewis and Clark County.
Round of applause.
And there are actually four other counties now from Montana that have E-cigarettes in their Clean Indoor Air Act protocol.
That's Sanders County, Carbon, Powell, and Granite recently added there then too.
I'll just mention too that in addition to those businesses in other, in other counties where this isn't a law, businesses have the authority and, and the um, and the right to ban E-cigarettes in their business.
So different businesses or housing authorities, um, hospitals, they can, they can choose to ban the use of E-cigarettes on their property.
So I did want to mention that lots of other localities across the national have taken it upon themselves to enact some policies that are even, even more strict on these products, and help protect our youth.
So in California, and Hawaii, they have made it illegal to purchase any tobacco product, including E-cigarettes, um, if you (cough) (excuse me) if you are under the age of 21.
So there are at least 225 other localities where it's illegal to purchase tobacco if you're under the age of 21.
So this is really good for a number of reasons.
Um, one is because it reduces, or it delays the age of initiation and then two, it helps keep tobacco out of schools, um, as Kris had mentioned earlier.
You have, have 18 year olds who can buy these products and they're still in high school.
When you raise the age to 21, you don't have a lot of 21 year olds who are still in high school, so it makes it difficult for those kids to be buying a tobacco product or E-cigarettes and passing along to their friends in high school.
And then the other reason is, um, it reduces sales to minors because it's harder to pass off as a 21 year old than it is to pass off as an 18 year old.
So, so doing that, that's a really, that's a really good policy that the Surgeon General promotes.
In Minnesota, they've applied a tax to E-cigarettes.
You heard Dr.
Shepard talk about how we've, we recently tried to do that and it didn't go so well.
But raising the price, raising the price on tobacco products is one of the most effective mechanisms to re, to prevent youth initiation of tobacco products.
So, like some other, um, some of our counties in Montana, New Jersey and our neighbor North Dakota, the whole state has prohibited the use of E-cigarettes in indoor public places.
So that's something that a whole state can do, is, is include that in the state Clean Indoor Air Act.
Um, Chicago has actually banned the sale of flavored products within 500 feet of a school.
So they're taking action on these flavors, because E-cigarettes, they come in 7,700 different flavors.
I mean, that, that's insane and, as Sarah mentioned, they're in all these different flavors that are appealing specifically to kids.
Um, Providence, Rhode Island has prohibited discounts like coupons and buy one, get one free.
And then New York City has actually had a law that requires that all of their tobacco products be placed behind the counter or in another area that's not freely accessible and can't just be picked up by a kid and walked out.
So this is just kind of a sample.
There are a lot of other localities across the nation that have taken action like this.
This is just a sample of some of the, some of the policies that are in place across the nation.
So what can you do? What we're wanting from the community outright is to, to know the facts so you've taken the right step today coming and hearing, hearing what we do know about E-cigarettes, so I applaud you for doing that.
The other thing is, talk to your kids and other young people about the risks associated with E-cigarettes, not just water vapor and now you guys know that.
And you know, find the right time to talk to them.
It may not just be, oh I'm going to pull my kid aside and we're going to have a sit down conversation in our living room.
Maybe take the opportunity when you're in a convenience store with your kid or with another young person, and you're seeing those tobacco products placed right next to the candy bars.
Take that moment to stop and say, "hey what do you think about this?" And get their thoughts on it.
Or if you see somebody, you're walking by somebody who's using an E-cigarette or if you're hearing, hearing advertisements on E-cigarettes.
Um, the other thing is, you know, reach out to other, other adults and, and talk to your decision makers, educate your decision makers about these products.
Like, like I said at the very beginning, there's so much misinformation about these products and depending on who you talk to, you're getting different types of, of facts.
So, it's really important that you're communicating to your decision makers and your legislatures, the real facts about these, about these E-cigarettes and what they're doing to our kids and why we're, why we're concerned.
And this can look at, look in a lot of different ways, it could, it could also take the form of, you know, writing, writing a letter to the editor for your newspaper, going and speaking at different groups.
So, so just getting, getting your voice out there is a good way too.
And the last one that I'd like to mention is, is really important, is lead by example.
You know, be tobacco-free yourself.
So if, if you are a tobacco user, there is help for you.
There's a Montana Tobacco Quit Line.
It offers free nicotine replacement therapy which is little gums and gum and lozenges and patches.
It offers reduced cost medication and free coaching.
These, these things like Dr.
Shepard mentioned, combined offer you the greatest success rate that you can get.
So there is help for you and, and it doesn't help to, it's harder for you to have a conversation with your kids about tobacco products and E-cigarettes, if you yourself are using them.
It's harder to get that message across.
So there is hope for you and your set, 1-800-QUIT-Now.