What are the risks of e-cigarettes for youth, young adults, and pregnant adults? E-cigarettes are the most commonly used tobacco product among youth. In the United States, youth are more likely than adults to use e-cigarettes. In , 2. More information. The devices and brands presented in this pamphlet are intended to highlight the different e-cigarette, or vaping, product generations and substances used in these devices.
Federal regulation of e-cigarettes: Provides an overview of FDA regulations of e-cigarettes and other tobacco products. State laws and policies regarding e-cigarettes : This CDC fact sheet reports on laws pertaining to sales, use, and taxation of e-cigarettes in the 50 states and the District of Columbia. E-Cigarettes Fact Sheet. E-cigarettes Fact Sheet. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the U.
Int J Drug Policy. Preventive Services Task Force. Evidence Synthesis No. Can electronic cigarettes help people stop smoking, and are they safe to use for this purpose? Prev Chronic Dis ; Bjartveit K, Tverdal A. Tobacco Control ;14 5 — Morbidity and Mortality Weekly Report, ; —9.
Morbidity and Mortality Weekly Report, Volume 69 issue 46 ; pages — What's this. E-cigarettes are still fairly new, and more research is needed over a longer period of time to know what the long-term effects may be. The most important points to know are that the long-term health effects of e-cigarettes are still unknown, and all tobacco products, including e-cigarettes, can pose health risks to the user.
For more information, see Health Risks of E-cigarettes. The American Cancer Society is closely watching for new research about the effects of using e-cigarettes and other new tobacco products.
See "What is in the aerosol "vapor" of an e-cigarette? No youth, including middle schoolers and high schoolers, should use e-cigarettes or any tobacco product. It is important to know that all JUULs and most other e-cigarettes contain addictive nicotine. Some studies have shown that vaping by some youth may be linked to later use of regular cigarettes and other tobacco products. Using e-cigarettes may play a part in some kids or teens wanting to use other, more harmful tobacco products. JUUL is the overwhelming favorite e-cigarette product among young people.
The FDA has the authority to regulate all tobacco products, including e-cigarettes. The FDA is working on several options to prevent youth access to e-cigarettes, such as recent legislation to raise the minimum age for the sale of tobacco products. Scientists are still learning about how e-cigarettes affect health when they are used for long periods of time. There have been reports of e-cigarettes exploding and causing serious injuries.
Usually the explosions are caused by faulty batteries or because the batteries were not handled as they should be. The FDA, which was given the power to regulate new tobacco products more than a decade ago, has been carrying out a study of e-cigarettes to decide which ones can continue to be sold.
A decision on the market leader, Juul, is still awaited. Explaining the FDA's reasoning, Mitch Zeller, its director for tobacco products said: "The manufacturer's data demonstrates its tobacco-flavoured products could benefit addicted adult smokers who switch to these products - either completely or with a significant reduction in cigarette consumption - by reducing their exposure to harmful chemicals.
He also warned that the authorisation could be withdrawn if there were signs of significant use of the product by people who did not previously use tobacco, including young people. It would seem that future studies should analyse the possible toxic effects of humectants and related products at concentrations similar to those that e-cigarette vapers are exposed to reach conclusive results.
The range of e-liquid flavours available to consumers is extensive and is used to attract both current smokers and new e-cigarette users, which is a growing public health concern [ 6 ].
Since , the FDA regulates the flavours used in the e-cigarette market and has recently published an enforcement policy on unauthorised flavours, including fruit and mint flavours, which are more appealing to young users [ 77 ]. However, the long-term effects of all flavour chemicals used by this industry which are more than 15, remain unknown and they are not usually included in the product label [ 78 ].
Furthermore, there is no safety guarantee since they may harbour potential toxic or irritating properties [ 5 ]. With regards to the multitude of available flavours, some have demonstrated cytotoxicity [ 59 , 79 ]. Bahl et al. In general, those e-liquids that were bubblegum-, butterscotch- and caramel-flavoured did not show any overt cytotoxicity even at the highest dose tested. By contrast, those e-liquids with Freedom Smoke Menthol Arctic and Global Smoke Caramel flavours had marked cytotoxic effects on pulmonary fibroblasts and those with Cinnamon Ceylon flavour were the most cytotoxic in all cell lines [ 79 ].
A further study from the same group [ 80 ] revealed that high cytotoxicity is a recurrent feature of cinnamon-flavoured e-liquids. In this line, results from GC—MS and HPLC analyses indicated that cinnamaldehyde CAD and 2-methoxycinnamaldehyde, but not dipropylene glycol or vanillin, were mainly responsible for the high cytotoxicity of cinnamon-flavoured e-liquids [ 80 ].
Other flavouring-related compounds that are associated with respiratory complications [ 81 , 82 , 83 ], such as diacetyl, 2,3-pentanedione or acetoin, were found in 47 out of 51 aerosols of flavoured e-liquids tested [ 84 ].
Allen et al. Assuming again puffs per cartridge and 40 mL per puff, is it is possible to estimate an average of 0. The cytotoxic and pro-inflammatory effects of different e-cigarette flavouring chemicals were also tested on two human monocytic cell lines—mono mac 6 MM6 and U [ 86 ].
Of interest, a higher toxicity was evident when combinations of different flavours or mixed equal proportions of e-liquids from 10 differently flavoured e-liquids were tested, suggesting that vaping a single flavour is less toxic than inhaling mixed flavours [ 86 ].
It should be borne in mind, however, that the concentrations assayed were in the supra-physiological range and it is likely that, once inhaled, these concentrations are not reached in the airway space. Indeed, one of the limitations of the study was that human cells are not exposed to e-liquids per se, but rather to the aerosols where the concentrations are lower [ 86 ].
Moreover, on a day-to-day basis, lungs of e-cigarette users are not constantly exposed to these chemicals for 24 h at these concentrations. Similar limitations were found when five of seven flavourings were found to cause cytotoxicity in human bronchial epithelial cells [ 87 ]. However, increased ROS production was registered in H cells [ 88 ].
Therefore, to fully understand the effects of these compounds, it is relevant the cell cultures selected for performing these assays, as well as the use of in vivo models that mimic the real-life situation of chronic e-cigarette vapers to clarify their impact on human health. While the bulk of studies related to the impact of e-cigarette use on human health has focused on the e-liquid components and the resulting aerosols produced after heating, a few studies have addressed the material of the electronic device and its potential consequences—specifically, the potential presence of metals such as copper, nickel or silver particles in e-liquids and aerosols originating from the filaments and wires and the atomiser [ 89 , 90 , 91 ].
Other important components in the aerosols include silicate particles from the fiberglass wicks or silicone [ 89 , 90 , 91 ]. Many of these products are known to cause abnormalities in respiratory function and respiratory diseases [ 89 , 90 , 91 ], but more in-depth studies are required. Interestingly, the battery output voltage also seems to have an impact on the cytotoxicity of the aerosol vapours, with e-liquids from a higher battery output voltage showing more toxicity to A cells [ 30 ].
Some rats received a single e-cigarette exposure for 2 h from a NC heating element 60 or 70 W ; other rats received a similar exposure of e-cigarette vapor using a SS heating element for the same period of time 60 or 70 W and, a final group of animals were exposed for 2 h to air. Thus, suggesting that operating units at higher than recommended settings can cause adverse effects.
Nevertheless, there is no doubt that the deleterious effects of battery output voltage are not comparable to those exerted by CS extracts [ 30 ] Figs. CS contains a large number of substances—about different constituents in total, with sizes ranging from atoms to particulate matter, and with many hundreds likely responsible for the harmful effects of this habit [ 93 ].
Given that tobacco is being substituted in great part by e-cigarettes with different chemical compositions, manufacturers claim that e -cigarette will not cause lung diseases such as lung cancer, chronic obstructive pulmonary disease, or cardiovascular disorders often associated with conventional cigarette consumption [ 3 , 94 ].
However, the World Health Organisation suggests that e-cigarettes cannot be considered as a viable method to quit smoking, due to a lack of evidence [ 7 , 95 ]. Indeed, the results of studies addressing the use of e-cigarettes as a smoking cessation tool remain controversial [ 96 , 97 , 98 , 99 , ]. Moreover, both FDA and CDC are actively investigating the incidence of severe respiratory symptoms associated with the use of vaping products [ 77 ].
Because many e-liquids contain nicotine, which is well known for its powerful addictive properties [ 41 ], e-cigarette users can easily switch to conventional cigarette smoking, avoiding smoking cessation. Nevertheless, the possibility of vaping nicotine-free e-cigarettes has led to the branding of these devices as smoking cessation tools [ 2 , 6 , 7 ]. In a recently published randomised trial of subjects who were willing to quit smoking [ ], the abstinence rate was found to be twice as high in the e-cigarette group than in the nicotine-replacement group Of note, the abstinence rate found in the nicotine-replacement group was lower than what is usually expected with this therapy.
Nevertheless, the incidence of throat and mouth irritation was higher in the e-cigarette group than in the nicotine-replacement group On the other hand, it is estimated that COPD could become the third leading cause of death in [ ].
Published data revealed a clear reduction of conventional cigarette consumption in COPD smokers that switched to e-cigarettes [ ]. Indeed, a significant reduction in exacerbations was observed and, consequently, the ability to perform physical activities was improved when data was compared with those non-vapers COPD smokers.
Nevertheless, a longer follow-up of these COPD patients is required to find out whether they have quitted conventional smoking or even vaping, since the final goal under these circumstances is to quit both habits. Based on the current literature, it seems that several factors have led to the success of e-cigarette use as a smoking cessation tool. First, some e-cigarette flavours positively affect smoking cessation outcomes among smokers [ ]. Second, e-cigarettes have been described to improve smoking cessation rate only among highly-dependent smokers and not among conventional smokers, suggesting that the individual degree of nicotine dependence plays an important role in this process [ 97 ].
Third, the general belief of their relative harmfulness to consumers' health compared with conventional combustible tobacco [ ]. And finally, the exposure to point-of-sale marketing of e-cigarette has also been identified to affect the smoking cessation success [ 96 ]. However, while a systematic review indicated that cigarette smoking is probably associated with enhanced damage from COVID, a meta-analysis did not, yet the latter had several limitations due to the small sample sizes [ ].
Interestingly, most of these reports linking COVID harmful effects with smoking or vaping, are based on their capability of increasing the expression of angiotensin-converting enzyme 2 ACE2 in the lung. It is well known that ACE2 is the gate for SARS-CoV-2 entrance to the airways [ ] and it is mainly expressed in type 2 alveolar epithelial cells and alveolar macrophages [ ]. To date, most of the studies in this field indicate that current smokers have higher expression of ACE2 in the airways reviewed by [ ] than healthy non-smokers [ , ].
However, while a recent report indicated that e-cigarette vaping also caused nicotine-dependent ACE2 up-regulation [ 42 ], others have revealed that neither acute inhalation of e-cigarette vapour nor e-cigarette users had increased lung ACE2 expression regardless nicotine presence in the e-liquid [ 43 , ]. In regard to these contentions, current knowledge suggests that increased ACE2 expression is not necessarily linked to enhanced susceptibility to SARS-CoV-2 infection and adverse outcome.
In fact, most of the deaths provoked by COVID took place in people over 60 years old of age [ ]. Therefore, it is plausible that the increased susceptibility to disease progression and the subsequent fatal outcome in this population is related to poor angiotensin Ang generation, the main peptide generated by ACE2, and probably to their inaccessibility to its anti-inflammatory effects. Furthermore, it seems that all the efforts towards increasing ACE2 expression may result in a better resolution of the pneumonic process associated to this pandemic disease.
Nevertheless, additional complications associated to COVID are increased thrombotic events and cytokine storm. In the lungs, e-cigarette consumption has been correlated to toxicity, oxidative stress, and inflammatory response [ 32 , ].
Therefore, taken together these observations, e-cigarette use may still be a potent risk factor for severe COVID development depending on the flavour and nicotine content.
In summary, it seems that either smoking or nicotine vaping may adversely impact on COVID outcome. The harmful effects of CS and their deleterious consequences are both well recognised and widely investigated.
However, and based on the studies carried out so far, it seems that e-cigarette consumption is less toxic than tobacco smoking. This does not necessarily mean, however, that e-cigarettes are free from hazardous effects. Indeed, studies investigating their long-term effects on human health are urgently required. In this regard, the main additional studies needed in this field are summarized in Table 3.
Additionally, there is still a lack of evidence of e-cigarette consumption as a smoking cessation method. Indeed, e-cigarettes containing nicotine may relieve the craving for smoking, but not the conventional cigarette smoking habit. Interestingly, there is a strong difference of opinion on e-cigarettes between countries. Whereas countries such as Brazil, Uruguay and India have banned the sale of e-cigarettes , others such as the United Kingdom support this device to quit smoking.
The increasing number of adolescent users and reported deaths in the United States prompted the government to ban the sale of flavoured e-cigarettes in The difference in opinion worldwide may be due to different restrictions imposed. Nevertheless, despite the national restrictions, users can easily access foreign or even counterfeit products online.
In regard to COVID pandemic, the actual literature suggests that nicotine vaping may display adverse outcomes. Therefore, follow up studies are necessary to clarify the impact of e-cigarette consumption on human health in SARS-CoV-2 infection.
In conclusion, e-cigarettes could be a good alternative to conventional tobacco cigarettes, with less side effects; however, a stricter sale control, a proper regulation of the industry including flavour restriction, as well as further toxicological studies, including their chronic effects, are warranted.
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