Patterns of electronic cigarette use and user beliefs about their safety and benefits: An Internet survey
TL;DR: E-cigarettes were primarily used to quit smoking or to reduce the harm associated with smoking, and were successful in helping the surveyed users to achieve these goals with 66% not smoking conventional cigarettes at all and 25% smoking under five cigarettes a day.
Abstract: Introduction and Aims
As the popularity of electronic cigarettes (e-cigarettes) increases, it is becoming important to find out more about the characteristics of e-cigarette users, why and how they use the product and whether e-cigarettes are used exclusively or in combination with conventional cigarettes. The objective of this study was to investigate patterns and effects of e-cigarette use and user beliefs about e-cigarette safety and benefits.
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TL;DR: The findings of this study are consistent with the idea that substituting tobacco cigarettes with e-cigarettes may substantially reduce exposure to selected tobacco-specific toxicants.
Abstract: Significance Electronic cigarettes, also known as e-cigarettes, are devices designed to imitate regular cigarettes and deliver nicotine via inhalation without combusting tobacco. They are purported to deliver nicotine without other toxicants and to be a safer alternative to regular cigarettes. However, little toxicity testing has been performed to evaluate the chemical nature of vapour generated from e–cigarettes. The aim of this study was to screen e-cigarette vapours for content of four groups of potentially toxic and carcinogenic compounds: carbonyls, volatile organic compounds, nitrosamines and heavy metals. Materials and methods Vapours were generated from 12 brands of e-cigarettes and the reference product, the medicinal nicotine inhaler, in controlled conditions using a modified smoking machine. The selected toxic compounds were extracted from vapours into a solid or liquid phase and analysed with chromatographic and spectroscopy methods. Results We found that the e-cigarette vapours contained some toxic substances. The levels of the toxicants were 9–450 times lower than in cigarette smoke and were, in many cases, comparable with trace amounts found in the reference product. Conclusions Our findings are consistent with the idea that substituting tobacco cigarettes with e-cigarettes may substantially reduce exposure to selected tobacco-specific toxicants. E-cigarettes as a harm reduction strategy among smokers unwilling to quit, warrants further study. (To view this abstract in Polish and German, please see the supplementary files online.)
1,398 citations
TL;DR: E-cigarette products are changing quickly, and many of the findings from studies of older products may not be relevant to the assessment of newer products that could be safer and more effective as nicotine delivery devices, so patterns of use and the ultimate impact on public health may differ.
Abstract: Electronic cigarettes (e-cigarettes) are products that deliver a nicotine-containing aerosol (commonly called vapor) to users by heating a solution typically made up of propylene glycol or glycerol (glycerin), nicotine, and flavoring agents (Figure 1) invented in their current form by Chinese pharmacist Hon Lik in the early 2000s.1 The US patent application describes the e-cigarette device as “an electronic atomization cigarette that functions as substitutes [sic] for quitting smoking and cigarette substitutes ” (patent No. 8,490,628 B2). By 2013, the major multinational tobacco companies had entered the e-cigarette market. E-cigarettes are marketed via television, the Internet, and print advertisements (that often feature celebrities)2 as healthier alternatives to tobacco smoking, as useful for quitting smoking and reducing cigarette consumption, and as a way to circumvent smoke-free laws by enabling users to “smoke anywhere.”3
Figure 1.
Examples of different electronic cigarette (e-cigarette) products. Reproduced from Grana et al.1
There has been rapid market penetration of e-cigarettes despite many unanswered questions about their safety, efficacy for harm reduction and cessation, and total impact on public health. E-cigarette products are changing quickly, and many of the findings from studies of older products may not be relevant to the assessment of newer products that could be safer and more effective as nicotine delivery devices. In addition, marketing and other environmental influences may vary from country to country, so patterns of use and the ultimate impact on public health may differ. The individual risks and benefits and the total impact of these products occur in the context of the widespread and continuing availability of conventional cigarettes and other tobacco products, with high levels of dual use of e-cigarettes and conventional cigarettes at the same time among adults4–8 and youth.9–11 It is important to assess e-cigarette toxicant exposure and …
961 citations
Cites background from "Patterns of electronic cigarette us..."
...Effects on Cessation of Conventional Cigarettes E-cigarettes are promoted as smoking cessation aids, and many individuals who use e-cigarettes believe that they will help them quit smoking conventional cigarettes.(7,29,30) The assumption that e-cigarettes will be as effective as or more effective than pharmaceutical NRTs has also motivated support for e-cigarettes among some public health researchers and policy makers(78) and (as discussed later) formed the basis for some public policies on the regulation of e-cigarettes....
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TL;DR: Exposure to e-cig aerosols/juices incurs measurable oxidative and inflammatory responses in lung cells and tissues that could lead to unrealized health consequences.
Abstract: Oxidative stress and inflammatory response are the key events in the pathogenesis of chronic airway diseases. The consumption of electronic cigarettes (e-cigs) with a variety of e-liquids/e-juices is alarmingly increasing without the unrealized potential harmful health effects. We hypothesized that electronic nicotine delivery systems (ENDS)/e-cigs pose health concerns due to oxidative toxicity and inflammatory response in lung cells exposed to their aerosols. The aerosols produced by vaporizing ENDS e-liquids exhibit oxidant reactivity suggesting oxidants or reactive oxygen species (OX/ROS) may be inhaled directly into the lung during a “vaping” session. These OX/ROS are generated through activation of the heating element which is affected by heating element status (new versus used), and occurs during the process of e-liquid vaporization. Unvaporized e-liquids were oxidative in a manner dependent on flavor additives, while flavors containing sweet or fruit flavors were stronger oxidizers than tobacco flavors. In light of OX/ROS generated in ENDS e-liquids and aerosols, the effects of ENDS aerosols on tissues and cells of the lung were measured. Exposure of human airway epithelial cells (H292) in an air-liquid interface to ENDS aerosols from a popular device resulted in increased secretion of inflammatory cytokines, such as IL-6 and IL-8. Furthermore, human lung fibroblasts exhibited stress and morphological change in response to treatment with ENDS/e-liquids. These cells also secrete increased IL-8 in response to a cinnamon flavored e-liquid and are susceptible to loss of cell viability by ENDS e-liquids. Finally, exposure of wild type C57BL/6J mice to aerosols produced from a popular e-cig increase pro-inflammatory cytokines and diminished lung glutathione levels which are critical in maintaining cellular redox balance. Thus, exposure to e-cig aerosols/juices incurs measurable oxidative and inflammatory responses in lung cells and tissues that could lead to unrealized health consequences.
503 citations
TL;DR: Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality and health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.
Abstract: Aims We reviewed available research on the use, content and safety of electronic cigarettes (EC), and on their effects on users, to assess their potential for harm or benefit and to extract evidence that can guide future policy. Methods Studies were identified by systematic database searches and screening references to February 2014. Results EC aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower. Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children. EC enable some users to reduce or quit smoking. Conclusions Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality. Regulating EC as strictly as cigarettes, or even more strictly as some regulators propose, is not warranted on current evidence. Health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.
484 citations
Cites background from "Patterns of electronic cigarette us..."
...EC were perceived as less addictive than cigarettes [35,37], and time from waking up to use was longer for EC than for cigarettes [36,37]....
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TL;DR: No firm conclusions can be drawn on the safety of ECs due to many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up.
437 citations
References
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TL;DR: A revision of the FTQ: the Fagerström Test for Nicotine Dependence (FTND), which found that a revised scoring of time to the first cigarette of the day (TTF) and number of cigarettes smoked per day (CPD) improved the scale.
Abstract: We examine and refine the Fagerstrom Tolerance Questionnaire (FTQ: Fagerstrom, 1978). The relation between each FTQ item and biochemical measures of heaviness of smoking was examined in 254 smokers. We found that the nicotine rating item and the inhalation item were unrelated to any of our biochemical measures and these two items were primary contributors to psychometric deficiencies in the FTQ. We also found that a revised scoring of time to the first cigarette of the day (TTF) and number of cigarettes smoked per day (CPD) improved the scale. We present a revision of the FTQ: the Fagerstrom Test for Nicotine Dependence (FTND).
9,766 citations
TL;DR: The European Community Respiratory Health Survey (ECRHS) was planned to answer specific questions about the distribution of asthma and health care given for asthma in the European Community.
Abstract: The European Community Respiratory Health Survey (ECRHS) was planned to answer specific questions about the distribution of asthma and health care given for asthma in the European Community. Specifically, the survey is designed to estimate variations in the prevalence of asthma, asthma-like symptoms and airway responsiveness; to estimate variations in exposures to known or suspected risk factors for asthma, and assess to what extent these variations explain the variations in the prevalence of disease; and to estimate differences in the use of medication for asthma. The protocol provides specific instructions on the sampling strategy adopted by the survey teams, as well as providing instructions on the use of questionnaires, the tests for allergy, lung function measurements, tests of airway responsiveness, and blood and urine collection. The principal data collection sheets and questionnaires are provided in the appendices, together with information on coding and quality control. The protocol is published as a reference for those who wish to know more of the methods used in the study, and also to give other groups who wish to collect comparable data access to the detailed methodology.
1,814 citations
Additional excerpts
...Those questions included items from the American Thoracic Society questionnaire and from the European Community Respiratory Health Survey [28,29]....
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Journal Article•
1,356 citations
TL;DR: This book represents an impressively comprehensive report on deaths from tobacco smoking between 1950 and 2000, tracing the smoking epidemic in developed countries over the past four decades and projecting how many more deaths tobacco will cause in the final decade of the century.
Abstract: This book represents an impressively comprehensive report on deaths from tobacco smoking between 1950 and 2000. It is a unique and authoritative record, tracing the smoking epidemic in developed countries over the past four decades and projecting how many more deaths tobacco will cause in the final decade of the century. It contains previously unpublished data for each major developed country (including figures for the individual countries within the former USSR). In addition, there are aggregated statistics for deaths from tobacco in the following groups: all developed countries, the former Socialist economies, the OECD developed countries, the current European Union (EU) (12 countries) and the planned EU (16 countries). It also contains some projections on deaths in developing countries. The work is aimed at clarifying for international governments, health professionals and the public, the real importance of the epidemic. Many of the figures and tables presented are designed for use as visual aids, and so most parts of the book may be reproduced freely without seeking copyright permission from the publisher or authors. Current death rates from smoking are presented for each separate developed country. These demonstrate the rapidly increasing mortality caused by smoking in both sexes which contrasts with the steadily decreasing mortality rates that have been seen among non-smokers in the 'OECD' developed countries. On almost every page, the scale of the numbers of deaths caused by smoking is alarming. The estimated average loss of life for those killed from smoking is about 16 years, and half of all regular smokers are eventually killed by their habit. On present trends, 4-5 million of young people (aged under 20) now living in the UK will eventually become regular smokers and tobacco will kill nearly half of them, with about 1 million of them killed by tobacco in middle age and another million in old age. Tobacco still causes one-third of all cancer deaths in the UK and between 1950 and 2000, tobacco will have killed about 6 million people in the UK. This is not to imply that all the data in this book is discouraging. Mortality from smoking in the UK has declined by about a fifth since 1970 as a result of a decline in cigarette sales and reductions in cigarette tar yields, and is still declining. Internationally, there are some striking differences. Thus in 1965, the UK had the worst mortality rates from smoking in the world whereas Poland had quite low rates. Now, however, the situation is reversed and Poland, like some of the other former socialist economies, is one of the worst-affected countries in the world. The final chapter deals with the spread of the epidemic to developing countires. Over the next few decades worldwide deaths from tobacco are projected to rise from 3 million a year now (including 'only' 1 million in the less-developed countries) to 10 million a year in about 2025 (including 7 million a year in less-developed countries). The contents of this book are overwhelmingly chastening. They also amount to a compelling case for governments everywhere to implement the World Health Organization's plea that children be protected from the advertising and promotion of tobacco. No-one and no organisation with an interest in public health or disease causation should be without this book.
985 citations
TL;DR: E-cigarettes were used much as people would use nicotine replacement medications: by former smokers to avoid relapse or as an aid to cut down or quit smoking, and for quitting and relapse prevention.
Abstract: Aims To assess the profile, utilization patterns, satisfaction and perceived effects among users of electronic cigarettes (‘e-cigarettes’). Design and Setting Internet survey in English and French in 2010. Measurements Online questionnaire. Participants Visitors of websites and online discussion forums dedicated to e-cigarettes and to smoking cessation. Findings There were 3587 participants (70% former tobacco smokers, 61% men, mean age 41 years). The median duration of electronic cigarette use was 3 months, users drew 120 puffs/day and used five refills/day. Almost all (97%) used e-cigarettes containing nicotine. Daily users spent $33 per month on these products. Most (96%) said the e-cigarette helped them to quit smoking or reduce their smoking (92%). Reasons for using the e-cigaretteincludedtheperceptionthatitwaslesstoxicthantobacco(84%),todealwithcravingfortobacco(79%)and withdrawal symptoms (67%), to quit smoking or avoid relapsing (77%), because it was cheaper than smoking (57%) and to deal with situations where smoking was prohibited (39%). Most ex-smokers (79%) feared they might relapse to smoking if they stopped using the e-cigarette. Users of nicotine-containing e-cigarettes reported better relief of withdrawalandagreatereffectonsmokingcessationthanthoseusingnon-nicotinee-cigarettes.Conclusions E-cigarettes were used much as people would use nicotine replacement medications: by former smokers to avoid relapse or as an aid tocutdownorquitsmoking.Furtherresearchshouldevaluatethesafetyandefficacyof e-cigarettesforadministration of nicotine and other substances, and for quitting and relapse prevention.
668 citations