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Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 108-112

Electronic Cigarettes: Needs urgent concern toward public health safety

1 Department of Public Health Dentistry, Sri Aurobindo Institute of Medical Sciences, Dental College, Bhopal, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, Bhaba College of Dental Sciences, Bhopal, Madhya Pradesh, India

Date of Web Publication3-May-2016

Correspondence Address:
Swati Balsaraf
B-204, Akanksha Apartments, Saims Staff Quarters, Sri Aurobindo Institute of Medical Sciences Campus, Ujjain Road, Indore - 453 111, Madhya Pradesh
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DOI: 10.4103/2249-9725.181677

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Electronic cigarette (E-cigarette) is an electronic nicotine delivery system which is a part of growing tobacco industry. It has a battery, atomizer, cartridge, and an indicator light. They are classified according to the generation or tier system. The latest are the seventh generation. It contains volatile organic compounds, diethylene glycol, and nicotine to name a few. It dates back to 2003 in China. There are increasing phenomena of awareness and sale of E-cigarettes on the internet. There are lots of questions unanswered regarding the safety and marketing of E-cigarettes. Until and unless approved by the World Health Organization, the safety of use of E-cigarettes should be considered caveat emptor. The literature was generated as a result of search of articles on PubMed and Google engine and Ebscohost by using key words E-cigarettes.

Keywords: Diethylene glycol, electronic-cigarettes, electronic nicotine delivery system, gateway effect, smoking cessation method, volatile organic compounds

How to cite this article:
Balsaraf S, Chole R. Electronic Cigarettes: Needs urgent concern toward public health safety. Univ Res J Dent 2016;6:108-12

How to cite this URL:
Balsaraf S, Chole R. Electronic Cigarettes: Needs urgent concern toward public health safety. Univ Res J Dent [serial online] 2016 [cited 2017 Jun 25];6:108-12. Available from: http://www.urjd.org/text.asp?2016/6/2/108/181677

  Introduction Top

Electronic cigarette (E-cigarette) is an electronic nicotine delivery system (ENDS) which is a part of growing tobacco industry. There are increasing phenomena of awareness and sale of E-cigarettes on the internet.[1] It is considered trendy, fashionable, attractive by the users, especially youths who mimics the traditional way of smoking and is of moderate cost. The products are promoted through television and entertainment celebrities.[2] The manufacturing companies boast about it being completely harmless which is still debatable. It is also considered a potential tobacco cessation device.[3] E-cigarettes are one of the most burning health issues at the moment because dozens of companies are trying to develop the nicotine market outside of pharmacies in Germany and other European Union countries, said Dr. Pötschke-Langer, head of the World Health Organization's (WHOs) Collaborating Centre for Tobacco Control in Heidelberg.[4] This article will throw light on the public health aspect and safety concerns of E-cigarettes. The literature was generated as a result of search of articles on PubMed, Ebscohost and Google engine by using key words E-cigarettes. Since the E-cigarettes are a growing industry and much talked about there is a need to summarize the health benefits and harms of E-cigarettes.

  Structure Top

ENDS is a term coined by the WHO for E-cigarette. It consists of a plastic tube which mimics a cigarette and consists of electronic heating element, electronic circuitry, and sensors which detect when the patient takes a drug. It also has an atomization chamber with a membrane to suspend ingredients, a replaceable liquid nicotine cartridge, and a rechargeable lithium battery.[5] When activated, the heating element vaporizes the liquid nicotine and the steam is absorbed orally. Its flavor ranges from bubblegum, chocolate, mint, fruit, and coffee to tobacco. Propylene glycol (1,2-propanediol) is the chemical used to generate artificial smoke.[6] Some E-cigarettes contain a light emitting diode in the tip which illuminates when the user inhales (or “vapes”), giving the appearance of the burning end of a conventional cigarette.[7] Smart technology is cited that shuts down the device if more than a specified number of inhalations are made within a certain time, or if a maximum duration of a single inhalation is reached so as to limit total nicotine intake.[8] The biggest criticism of the “E-cigarettes” on the market is that while replicating the art of smoking so well, they are bigger and heavier than the real thing.[9] So called electronic “cigarettes” are one of the most new type of potential reduced exposure products which are sold at retail market and over internet the most.[10] E-cigarettes are reported to last for about 200 puffs.[11]

  History Top

Hon Lik patented the modern E-cigarette design in 2003 in China. The company that Lik worked for, Golden Dragon Holdings, changed its name to Ruyan (literally “Resembling smoking”), and started exporting its products in 2005–2006, before receiving its first international patent in 2007.[12]

  Classification Top

E-cigarettes are classified according to tier or groups. The first generation/Tier 1 models resemble the real thing as closely as possible but very small batteries and limited power. They are basic in every aspect, and no improvements in performance can be made since those depend on more battery power being available. Typical Tier 1 models are two-piece or three-piece. A two-piece E-cigarette comprises a battery and cartomizer, which is a combined atomizer and liquid cartridge. Each cartridge in a three-piece model contains liquid equivalent to about 4 cigarettes, while two-piece cartomizer models hold a little more, usually around 6 cigarettes' equivalent. The battery type determines whether it is an auto or manual model, although they can be exchanged since the threading is identical (within the same model range). A manual model has a small press switch to operate the unit. The auto version has a pressure switch that activates on demand, although some older models had an audio switch - A microphone insert that activated the battery if the sound of air passing through was detected. Inevitably, these models suffered from issues in high-noise environments. In Tier 2 models or the second generation E-cigarettes battery life is between 4 and 10 times better than in Tier 1. Most Tier 2 models are manual. The Tier 3 models are uprated models which are usually referred to as “mods” because they started life as modifications and improvements of existing equipment featuring large batteries. All Tier 3 models are manual, not auto. The diamond series are the new fourth generation E-cigarette: This is the disposable version diamond E-cigarette with its own battery component, and cartomizer in one neat little package.[13] In the fifth generation, there is a large battery, 5 mouthpieces to fill your own E-liquid into it, 2 cartomizers, and battery charger for all day vaping.[14] In the sixth generation, there is powerful long life lithium battery. This rechargeable E-cigarette consists of two components, the battery and the cartomizer (filling). After the battery has been charged, screw the cartomizer onto the battery and you can immediately start smoking electronically. The battery is empty when the blue light starts to flash. You see that the cartomizer is empty if no smoke comes out such as clubsmoker. In the seventh generation, E-cigarettes latest 2012 come with 3.9 Li-ion battery (mAh 280). Two piece design, battery, and atomizer are combined in a single piece. The cartridge contains 1.2 ml of liquid nicotine. It has dual flow air sensor which makes the auto start function more and accurate while LED tip at the top indicates working of battery.[11],[15]

The additional presence of irritants, solvents, genotoxins, and animal carcinogens (e.g., butyl acetate, diethyl carbonate, benzoic acid, quinoline, and dioctyl phthalate 2, 6-dimethyl phenol) is of unclear significance but needs further consideration.[16]

  Popularity Top

ENDS have emerged as an online leader in popularity among smoking alternatives in Canada, the UK, the USA, and Australia. Transgeographic analysis suggested ENDS searches were greater under stronger tobacco control, suggesting ENDS helps smokers circumvent or quit in response to smoking restrictions. Moreover, search trends for shopping and information-seeking ENDS searches were similar, implying that searches may lead to purchases.[6]

In a study done by Adkison et al. respondents in the USA (odds ratio [OR] = 4.86, confidence interval [CI] = 4.09, 5.77) and the UK (OR = 2.090, CI = 1.77, 2.47) had greater odds of having heard of ENDS than those in Canada, whereas Australian respondents had lower odds. Heavy smokers (≥20 cpd) had the greatest (OR = 1.24, CI = 1.04, 1.48) and long-term quitters had the lowest odds (OR = 0.83, CI = 0.69, 1.00) of awareness. Consistent with the Chi-square analysis, young, well-educated, higher-income, male smokers, and those who responded via the internet had greater odds of ENDS awareness. Among those aware, younger and female respondents were more likely to try ENDS. Current rather than former smokers and current nondaily smokers were more likely to try ENDS.[8]

  Advertisement Top

In the United Kingdom, for example, a recent brochure promoting a device called Gamucci-a name remarkably such as the prestigious fashion brand Gucci-used images of attractive young people in social, party-like situations. It looked as though the creative team of an advertisement agency that had once targeted young people with regular cigarette brands had simply picked up again from where they had previously left off.[7]

In recent months, ENDS have started to appear in popular entertainment through movies, television shows, and on air advocacy by Hollywood celebrities. On January 07, 2011, the Los Angeles Times noted that ENDS were used by movie star Johnny Depp in the recently released film The Tourist. On September 27, 2010, star Katherine Heigl appeared on “The Late Show with David Lettermen,” where both she and Mr. Lettermen used ENDS. Ms. Heigl stated that she was using the device to quit smoking.[2]

Manufacturers, distributors, and marketers of E-cigarettes say that they are an effective and healthier alternative to tobacco smoking, because the user does not inhale harmful tobacco smoke, which contains over 4000 toxic chemicals.[17] Interest in E-cigarettes seems to be increasing rapidly, fueled in part by the internet.

Google labels “E-cigarettes” as a breakout term, defined as a phrase that has experienced a change in growth > 5000%, with a very large increase over the past 2 years. Consumers are probably using the Internet as their main source of E-cigarette information. One novel approach used by E-cigarette companies is their internet-based marketing strategy. These companies use “affiliate marketing schemes” in which product users can become distributors and earn profits from recruiting customers.[18]

  Public Health Concerns Regarding Use of Electronic Cigarettes Top

Gateway effect

Some public health advocates are concerned that E-cigarettes a fashion gadget, which come in a variety of flavors, will appeal to youths and children leading to nicotine dependence and potentially tobacco use as well.[19] Young adults perceive the E-cigarette packaging are flashy and designed to attract attention and induce curiosity among people to use them.[20]

They undermine smoke-free laws

Due to which they were banned in Canada and Australia, also as the product is “smoked,” therefore, not permissible under the 2006 New Jersey Smoke-Free Air Act.[21] Given the restrictions on public smoking, some cigarette smokers may be encouraged to purchase E-cigarettes to circumvent the tobacco control regulations, as the E-cigarette industry encourages dual use by advertising that the public use of E-cigarettes is not restricted and is, therefore, legal to use in restaurants, bars, and other indoor areas where cigarette smoking is strictly prohibited.[12]

  How Safe are they? Top

The WHO and the US Food and Drug Administration (US FDA) have warned against the widespread use of E-cigarettes as a nicotine replacement product. Both bodies have recognized that E-cigarettes may be less harmful than tobacco smoking, given the lack of tar in E-cigarettes, but they emphasize that E-cigarettes are almost certainly more dangerous than medicinal nicotine replacement products.[12],[21] The FDA found that one cartridge contained 1% diethylene glycol, a known toxicant that has been involved in prior mass poisonings.[7] Given the lack of evidence regarding E-cigarettes' safety or efficacy as a smoking cessation aid, Australia, Canada, Singapore, and Brazil have banned the sale of E-cigarettes.[12],[22]

In a study done by Vardavas et al., it was found that E-cigarette use was associated with an immediate decrease in exhaled fraction of exhaled nitric oxide concentrations. Nitric oxide is a gaseous mediator which has an important role in several physiological processes in the respiratory tract including vascular regulation, neurotransmission, host-defense, and cytotoxicity. Nitric oxide is an additional marker that has been implicated in the pathophysiology of airway diseases associated with smoking and is strongly correlated with eosinophilic inflammation and bronchial hyper-reactivity and has become an established research tool for assessing oxidative stress indicating the immediate effect E-cigarette usage might have on pulmonary homeostasis.[23]

In a study done by Trtchounian et al. 2010, all brands of E-cigarettes required increases in pump speed during the course of the smoke-out interval. The density of the aerosol produced by E-cigarettes decreased, in most cases fairly rapidly, as the E-cigarette was smoked. Aerosol density could be increased by increasing the peristaltic pump speed up to a point after which even the highest pump speed did not produce any aerosol indicating erratic dosing with E-cigarettes.[11]

E-cigarettes, seen by many as a healthy alternative to tobacco smoking do cause damage to the lungs, scientists from the University of Athens, Greece, explained at the European Respiratory Society's Annual Congress 2012, Vienna, on Sunday 02, September. The results of a study carried out by Gratziou et al. showed that using an E-cigarette caused an instant significant increase in airway resistance that lasted for 10 min. However, more research is needed to understand whether this harm also has lasting effects in the long-term.[17]

The consumption of E-cigarettes causes emissions of aerosols and volatile organic compounds, such as 1,2-propanediol, flavoring substances, and nicotine, into indoor air. During inhalation of E-cigarette vapor, the aerosol size distribution alters in the human lung and leads to an exhalation of smaller particles. This effect is caused by the evaporation of the liquid particles in the lung and also in the environment after exhalation. The quantity of the inhaled vapor could be observed to depend on the liquid delivery system of the E-cigarette in use. With regard to a health-related evaluation of E-cigarette consumption, the impact of vapor inhalation into the human lung should be of primary concern.[24]

  Are they Really Smoking Cessation Aids? Top

In a case series study done by Caponnetto et al. in the year 2011 suggests that E-cigarettes are effective in helping quit people smoking who have shown constant relapse after undergoing various smoking cessation methods.[25]

The distinct and unique advantage of E-cigarettes is that they allow individuals to utilize one device that can simultaneously address nicotine withdrawal, psychological factors, and behavioral cues that serve as barriers to smoking abstinence. The finding that most individuals who used E-cigarettes at least reduced the number of tobacco cigarettes they smoked suggests that if proven safe, E-cigarettes may be a potentially important tool for harm reduction, especially among smokers who have found currently available pharmaceutic smoking-cessation options to be ineffective.[26]

A study done by Polosa et al. showed E-cigarette strongly suppressed cigarette use. However, no correlations were observed between the number of nicotine cartridges/day used and the level of smoking reduction. Furthermore, the observed positive effect of the E-cigarette is not due to nicotine delivery rather, the strong suppression of smoking in association with the absence of correlation between cartridges use and level of smoking reduction, suggests that the positive effect of the E-cigarette may be also due to its capacity to provide a coping mechanism for conditioned smoking cues by replacing some of the rituals associated with smoking gestures (e.g., hand-to mouth action of smoking).[27]

In a survey done by Etter and Bullen, E-cigarettes were used largely by former smokers as an aid to quit smoking, to avoid relapse and to deal with withdrawal symptoms, much as people use nicotine replacement therapy.[28]

  Regulation (Jurisdictions Restricting Elecrtonic Cigarette Use and/or Sales) Top

These products should be subject to the same restrictions on advertising and promotion as other tobacco products with changes (probably easing of restrictions) made only after careful consideration of the implications.[29] The FDA's position is that ENDS meet the definition of a drug delivery device under the Food, Drug, and Cosmetic Act and should be regulated accordingly; just as nicotine inhalers are regulated.[8] The UK Medicines and Healthcare Products Regulatory Agency (MHRA) says the E-cigarette is a medicinal product as defined by article 1 of European directive 2001/83/EC on the code relating to medicinal products for human use. The MHRA which insists it “does not want to see useful products removed from the market.” Nevertheless recognizes that this “will have an economic impact on importers of these products” and even that some companies could go out of business.[3] Local, county, state and international jurisdictions are restricting or banning the sale or use of E-cigarette products. New Jersey is the first state in the USA to ban the use of E-cigarettes in public places and workplaces, effective March 13, 2010, and banning E-cigarette sales to people 18 years and younger. A University of Michigan poll released September 13, 2010, shows that adults support restrictions on E-cigarettes.[21]

Korea Food and Drug Administration (KFDA) authorized the sales of E-cigarettes containing no nicotine as an “electronic smoking desire reducer.” Although the KFDA officially stated that the safety of E-cigarettes and its efficacy as a smoking cessation aid have not yet been scientifically proven, the E-cigarette industry currently advertises their products with a message claiming that “E-cigarettes are authorized by the KFDA, thus it is safe.” In fact, the KFDA's authorization of the sales of E-cigarettes is misleading to the public and has potential threats to public health.[12]

  Conclusion Top

Until and unless, it has been demonstrated sufficiently that the benefits of E-cigarettes outnumber its adverse effects, there should be a strict regulation over the sale and advertisement of such products in agreement with the recommendations of the WHO and the US FDA and should be considered unsafe and unacceptable and a caveat emptor. More research should be done to find the prevalence, behavior, attitude, and safety of E-cigarette use among people.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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