Adverse Effects of e-Cigarette Exposures

Intention to quit electronic cigarette smoking among university students who are e-cigarette users

OBJECTIVE

To identify factors that are significantly associated with the intention to quit electronic cigarette smoking (ECS) at multiple, ecological levels among university students.

PARTICIPANTS

365 students who were e-cigarette users from Seoul metropolitan areas, South Korea.

METHODS

A cross-sectional study through an online survey.

RESULTS

Of participants, 62.7% had the intention to quit ECS-17.2% within one month, 14.0% within six months, and 31.5% when the time is right. Factors significantly associated with the intention to quit ECS were identified: "device type," "a shorter duration of ECS," and "having started ECS for quitting traditional cigarette smoking" at the intrapersonal-level; "negative attitudes of either peers or family members toward ECS" at the interpersonal-level; and "exposure to community smoking cessation educations" at the community-level.

CONCLUSIONS

Approximately one-thirds of university e-cigarette users had no intention to quit ECS. The factors identified should be integrated into university level, behavioral smoking cessation strategies.

Nicotine Affects Multiple Biological Processes in EpiDermTM Organotypic Tissues and Keratinocyte Monolayers

Dermal exposure to nicotine is common due to the widespread use of tobacco products. Here, we assessed the effects of nicotine at concentrations found in thirdhand smoke (THS) contaminated environments and electronic cigarette (EC) spills or leaks on a 3D human skin model (EpiDermTM) and on submerged keratinocyte cultures. Air liquid interface treatment of EpiDermTM with 10 or 400 μg/mL of nicotine for 24 h followed by proteomics analysis showed altered pathways related to inflammation, protein synthesis, cell–cell adhesion, apoptosis, and mitochondrial function. Submerged cultured keratinocytes were used to validate the proteomics data and further characterize the response of skin cells to nicotine. Mitochondrial phenotype changed from networked to punctate in keratinocytes treated with 10 or 400 μg/mL of nicotine for 48 h and 24 h, respectively. After 72 h, all concentrations of nicotine caused a significant decrease in the networked phenotype. In Western blots, keratinocytes exposed to 400 μg/mL of nicotine had a significant decrease in mitofusin 2, while mitofusin 1 decreased after 72 h. The shift from networked to punctate mitochondria correlated with a decrease in mitofusin 1/2, a protein needed to establish and maintain the networked phenotype. Mitochondrial changes were reversible after a 24 h recovery period. Peroxisomes exposed to 400 μg/mL of nicotine for 24 h became enlarged and were fewer in number. Nicotine concentrations in THS and EC spills altered the proteome profile in EpiDermTM and damaged organelles including mitochondria and peroxisomes, which are involved in ROS homeostasis. These changes may exacerbate skin infections, inhibit wound healing, and cause oxidative damage to cells in the skin.

A qualitative examination of e-cigarette use among California young adults during the EVALI outbreak

The 2019 outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) increased awareness of potential health risks associated with vaping among the general public. Little is known, however, about how unfolding information regarding EVALI affected knowledge, attitudes, and behaviors among e-cigarette users, particularly among young adults. This study describes attitudinal and behavioral responses to EVALI among young adult e-cigarette users. In October and November 2019, seven focus groups were held with college-going young adult tobacco users from two four-year public universities in California. Focus groups included questions regarding knowledge of and reaction to EVALI news, and how the news affected product use. Text from current e-cigarette users was extracted to develop individual phenomenological textural-structural descriptions of e-cigarette use for 38 individuals which were used to create a composite experience of e-cigarette use in light of EVALI. Experiences indicated that e-cigarette users were aware of information regarding EVALI and received information from numerous sources. Information was filtered for legitimacy of EVALI claims and causes of EVALI. Risk rationalizations were developed to assess potential harm of continued e-cigarette use and provided reasoning for behavioral responses to EVALI. The emerging harm associated with EVALI prompted e-cigarette users to engage in a cognitive process resulting in employment of a range of rationalities to justify continued use. These results suggest how environmental, cognitive, and behavioral factors may interact as young adults negotiate e-cigarette-related harms.

Ocular conditions and dry eye due to traditional and new forms of smoking: A review

Addiction to cigarette smoking has high prevalence rates recorded worldwide. Smoking has been linked to several life-threatening systemic conditions such as cancer, heart attack and stroke, in addition to a range of ocular pathologies. In recent years, electronic cigarettes (EC) have emerged as alternatives to smoking. ECs are nicotine delivery devices which produce an aerosol by heating, rather than combusting, a liquid which contains nicotine, flavours and preservatives. This review focuses on the association of traditional and new forms of smoking with dry eye disease, contact lens wear and four other common ocular diseases: cataract, age-related macular degeneration, glaucoma and Graves' ophthalmopathy. It is concluded that smoking and vaping appear as a risk factor for the aforementioned ocular conditions. An evidence-based, clear link between cigarette smoking, or EC vaping and ocular problems is yet to be discovered.

Near fatal intoxication by nicotine and propylene glycol injection: a case report of an e-liquid poisoning

BACKGROUND

Concern about intoxication by e-liquid is growing as calls to poison control centers have increased since their introduction. Only three cases of intoxication by injection have been reported worldwide. Our case is unique because of the precise follow-up of a patient who survived a lethal dose of self-injected e-liquid, without other co-intoxication.

CASE PRESENTATION

A 51-year-old male presented to the Emergency Department after injecting himself intravenously (IV) in the forearm with 10 mL of e-liquid (1000 mg of nicotine diluted in propylene glycol). An agitation phase was followed by coma and bradypnoea requiring mechanical ventilation. The patient developed a transitory neurological impairment with the appearance of tetraparesis, gaze palsy and myoclonus due to nicotinic syndrome. The arterial blood gas (ABG) analysis confirmed uncompensated lactic acidosis with an elevated anion gap, which is an expected effect of propylene glycol. The toxicology screen indicated the presence of nicotine and cotinine in the blood and excluded the presence of concomitant intoxication. The patient recovered without sequelae.

CONCLUSION

Even a small quantity of intravenous (IV) e-liquid can lead to an acute intoxication and fatal outcomes due to the toxic effects of nicotine. This case might help emergency doctors cope with acute intoxication by injection of e-liquid and increase their comprehension of the two main substances, nicotine and propylene glycol with overview of their pharmacodynamics and kinetic effects.

Intention to Try Tobacco Among Middle School Students in a Predominantly Rural Environment of Central Appalachia

BACKGROUND

Disparities in tobacco use exist across regions in the United States. The Central Appalachian region carries some of the very high rates of tobacco use prevalence but research on tobacco use initiation is sparse.

OBJECTIVE

To investigate the intention to try tobacco and its associated factors among nonsmoking youth.

METHOD

Data were obtained from school-based tobacco surveys (n = 539) conducted in 11 middle schools (6th-8th grades; aged 10-15 years) in Northeast Tennessee in 2015-2016. Nonsmoking participants without firm commitment to abstain from trying tobacco in the next year were considered to have an intention to try tobacco. The Full Information Maximum Likelihood estimation (FIML) method in Mplus was employed to conduct a multivariable logistic regression analysis to delineate correlates of intention to try tobacco.

RESULTS

Overall, 20.0% of participants had intention to try tobacco. Among participants with intention to try tobacco, 53.7% owned tobacco-branded item(s), 86.1% believed that tobacco users have more friends, and 88.9% lived with tobacco users. In the adjusted logistic model, ever use of tobacco products, home smoking rules, owning tobacco-branded item(s), living with tobacco users, believing that tobacco users have more friends, and perception of easy access to tobacco products were significantly associated with intention to try tobacco (p < .02).

CONCLUSION

This study suggests that individual, interpersonal, and community level factors influence intention to try tobacco in this environment where tobacco pre-emption laws impede development of local tobacco control policies and regulations. Thus, efforts should focus on tobacco use initiation preventive programs, including school-based tobacco control programs.

E-cigarettes-An unintended illicit drug delivery system

Since the introduction of electronic cigarettes (e-cigarettes) in 2003, the technology has advanced allowing for greater user modifications, with users now able to control voltage, battery power, and constituents of the e-cigarette liquid. E-cigarettes have been the subject of a growing body of research with most research justifiably focused on the chemical makeup and risk analysis of chemicals, metals, and particulates found in e-cigarette liquids and vapor. Little research to date has focused on assessing the risks associated with the drug delivery unit itself and its potential for use as an illicit drug delivery system. In light of this, a range of illicit drugs was researched focusing on pharmacodynamics, usual method of administration, the dosage required for toxicity, toxic effects, and evidence of existing use in e-cigarettes in both literature and online illicit drug forums. A systematic literature search found evidence of current use of e-cigarettes to vape almost all illicit drug types analyzed. This presents both a potential population health risk and a management issue for clinicians. It also raises the issue of policing illicit drugs due to potential altered characteristic smells and storage within e-cigarette fluids. E-cigarettes are a viable illicit drug delivery system with evidence both inside and outside of the formal medical literature detailing their potential use for drug delivery of a wide range of illicit and legal drugs.

Patterns, Perception and Behavior of Electronic Nicotine Delivery Systems Use and Multiple Product Use Among Young Adults

BACKGROUND

Electronic nicotine delivery systems (ENDS) are battery-operated devices used to inhale vaporized or aerosolized nicotine. There is increasing research uncovering negative health effects of these devices. Less is known about the social and behavioral aspects among college students.

METHODS

This cross-sectional study was conducted at a mid-sized private university in Florida. The survey was sent via e-mail to the student body of undergraduates. A final sample size of 989 students was analyzed to understand demographic differences between users and nonusers, initiation factors, and influencers, as well as multiple product behaviors.

RESULTS

Approximately 51.4% (n = 508) of participants reported ever using an ENDS and other tobacco consumption. Males were significantly more likely to be users of ENDS. Polytobacco use, or the use of multiple tobacco products, was also more common among participants who have tried ENDS (P < .001). Perceptions of harm of both the primary and secondary vapor were considered to be less than that of conventional cigarettes. Peers were the primary influencer for initial use. A 4-class latent variable model differentiated between usage patterns characterized as abstainers (70%), hookah users only (14%), ENDS only (11%), and polytobacco users (4%).

CONCLUSIONS

ENDS are not commonly used as a quit tool among college students, but rather as a secondary source of nicotine, most commonly in current smokers.

E-Cigarette Toxicity?

Tobacco smoking is the most preventable cause of morbidity and mortality. In just a few short years, electronic cigarettes (e-cigarettes) have become increasingly popular, especially for younger individuals. Many people believe that e-cigarettes are safe. The inhaled aerosols of e-cigarettes contain numerous potential toxicities, some of which could be dangerous for health with long-term use. The safety of prolonged aerosol exposure is not known. The use of e-cigarettes as a harm-reduction tool at stopping tobacco smoking is not uniformly successful. E-cigarettes may be safer than tobacco products, but repeated prolonged exposure to their aerosols has its own considerable potential risk. The long-term health consequences of their use remain to be established. Physicians should vigorously discourage the use of e-cigarettes and tobacco products, with special emphasis on abstinence for younger people and during pregnancy or lactation.

The Use of E-cigarettes Among School-Going Adolescents in a Predominantly Rural Environment of Central Appalachia

E-cigarette use among youth in the United States (U.S.) continues to increase. In the rural Northeast Tennessee, where prevalence of tobacco use is higher than national and state averages, there is no literature on e-cigarette use to inform policies and programs. This study aimed to estimate the prevalence of e-cigarette use and examine association of e-cigarette use with two tobacco products among school-going adolescents. Data from 894 participants of a school-based survey conducted in 2016 in Northeast Tennessee were analyzed. Descriptive statistics and logistic regression analyses were conducted to estimate the prevalence and delineate the associations between e-cigarette use and other tobacco products. Approximately 11% of the participants currently used e-cigarettes, and 35% had ever used e-cigarettes. About 6% of the participants were current users of both e-cigarettes and cigarettes; 4% were current users of e-cigarettes and smokeless tobacco; 3% were current users of all three products, and 15% had ever tried all three products. More than one-half of current e-cigarette users (52%) also smoked cigarettes. Adjusting for covariates, current e-cigarette use was positively associated with cigarette smoking [Odds Ratio (OR) 27.32, 95% confidence interval (CI) 14.4-51.7] and smokeless tobacco use [OR 7.92, 95% CI 3.8-16.5]. E-cigarette use was more common among the high school students than cigarette and smokeless tobacco use, and a significant proportion of users either smoked cigarettes, used smokeless tobacco, or both. Thus, there is a critical need for preventive policies and programs to address dual and poly-use of these products.

Counterfeit Electronic Cigarette Products with Mislabeled Nicotine Concentrations

OBJECTIVES

We compared nicotine concentrations in one brand of refill fluids that were purchased in 4 countries and labeled 0 mg of nicotine/mL. We then identified counterfeit e-cigarette products from these countries.

METHODS

Overall, 125 e-cigarette refill fluids were purchased in Nigeria, the United States (US), England, and China. Nicotine concentrations were measured using high performance liquid chromatography and compared to labeled concentrations. Refill fluids were examined to identify physical differences and grouped into authentic and counterfeit products.

RESULTS

Whereas nicotine was in 51.7% (15/29) of the Nigerian, 3.7% (1/27) of the Chinese and 1.6% (1/61) of the American refill fluids (range = 0.4 - 20.4 mg/mL), 8 British products did not contain nicotine. Products from China, the US, and Nigeria with trace amounts of nicotine (0.4 to 0.6 mg/mL) were authentic; however, all products from Nigeria with more than 3.7 mg/mL were counterfeit.

CONCLUSIONS

We introduce 2 novel issues in the e-cigarette industry, the production of counterfeit refill fluids under a brandjacked label and inclusion of nicotine in 81.3% of the counterfeit products labeled 0 mg/mL. This study emphasizes the need for better control and monitoring of nicotine containing products and sales outlets.

Electronic cigarettes: what are they and what do they do?

Electronic cigarettes (ECIGs) use electricity to power a heating element that aerosolizes a liquid containing solvents, flavorants, and the dependence-producing drug nicotine for user inhalation. ECIGs have evolved rapidly in the past 8 years, and the changes in product design and liquid constituents affect the resulting toxicant yield in the aerosol and delivery to the user. This rapid evolution has been accompanied by dramatic increases in ECIG use prevalence in many countries among adults and, especially, adolescents in the United States. The increased prevalence of ECIGs that deliver nicotine and other toxicants to users' lungs drives a rapidly growing research effort. This review highlights the most recent information regarding the design of ECIGs and their liquid and aerosol constituents, the epidemiology of ECIG use among adolescents and adults (including correlates of ECIG use), and preclinical and clinical research regarding ECIG effects. The current literature suggests a strong rationale for an empirical regulatory approach toward ECIGs that balances any potential ECIG-mediated decreases in health risks for smokers who use them as substitutes for tobacco cigarettes against any increased risks for nonsmokers who may be attracted to them.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

A randomised, parallel group study to evaluate the safety profile of an electronic vapour product over 12 weeks

A randomised, parallel group clinical study was performed to evaluate the safety profile of an e-vapour product (EVP; 2.0% nicotine) in smokers of conventional cigarettes (CCs) switching to use the EVP for 12 weeks. During the study, no clinically significant product-related findings were observed in terms of vital signs, electrocardiogram, lung function tests and standard clinical laboratory parameters. Adverse events (AEs) reported by EVP subjects were more frequent during the first week after switching to the EVP. The frequency of AEs reduced thereafter and out of a total of 1515 reported AEs, 495 were judged as being related to nicotine withdrawal symptoms. The most frequently stated AEs were headache, sore throat, desire to smoke and cough reported by 47.4, 27.8, 27.5 and 17.0% of subjects, respectively. Only 6% of AEs were judged as probably or definitely related to the EVP. Additional observations in EVP subjects included a decrease in the level of urine nicotine equivalents by up to 33.8%, and decreases in the level of three biomarkers of exposure to toxicants known to be present in CC smoke (benzene, acrolein and 4-[methylnitrosamino]-1-[3-pyridyl]-1-butanone). The decrease in nicotine equivalents coincided with an increase in nicotine withdrawal symptoms, measured by a questionnaire, which subsided after two weeks. The data presented here shows the potential EVPs may offer smokers looking for an alternative to CCs.

Electronic Cigarette Toxicity

Electronic cigarettes (e-cigarettes) are often advertised as a healthier product when compared with traditional cigarettes. Currently, there are limited data to support this and only a threat of federal regulation from the US Food and Drug Administration. Calls to poison control centers about e-cigarette toxicity, especially in children, and case reports of toxic exposures have increased over the past 3 years. This research letter reports the frequency of hazardous exposures to e-cigarettes and characterizes the reported adverse health effects associated with e-cigarette toxicity.

Intravenous and oral suicidal e-liquid poisonings with confirmed nicotine and cotinine concentrations

The increasing availability of e-cigarettes is a potential toxicological concern. E-cigarettes appeared on the Polish market in 2006, and since 2009 they have been widely available with a new source of nicotine, the so-called e-liquid. In this paper two cases of suicidal oral and intravenous poisonings with the e-liquid are described. The clinical courses of these poisonings are presented. Nicotine and cotinine concentrations in the patient's blood were determined using high performance liquid chromatography with diode array detection. In the course of intoxication patient No. 1, classic symptoms of acute nicotine poisoning without convulsions were observed. Nicotine and cotinine concentrations measured in serum were 0.096 and 4.4mg/L, respectively. The case of patient No. 2, admission with no typical symptoms of nicotine poisoning was identified, except unconsciousness and slow respiration. Nicotine and cotinine concentrations in the serum at the time of No. 2 admissions were determined to be 0.8 and 1.3mg/L, respectively. With the increasing number of e-liquid poisonings cases, it should be aware that these products can be a readily available source of poison.

A public health strategy for e-cigarettes

The e-cigarette may present a new and significant Public Health problem: Studies published so far do not seem to indicate that e-cigarette use is just a passing trend. If e-cigarette use is less harmless than it is portrayed in many advertisements, Public Health would do well to start a serious discussion about a suitable prevention policy as soon as possible.The aim of this short paper is to discuss a range of measures designed to prevent e-cigarette consumption.Concretely, we suggest to monitor e-cigarette use, the e-cigarette industry and prevention policies, to implement a vapor-free policy, to develop help to quit e-cigarette use, to inform about the health risks of e-cigarette use, to establish regulations on e-cigarette advertising, promotion and sponsorship, and to introduce taxes on e-cigarettes.

Electronic cigarettes: incorporating human factors engineering into risk assessments

Objective

A systematic review was conducted to evaluate the impact of human factors (HF) on the risks associated with electronic cigarettes (e-cigarettes) and to identify research gaps. HF is the evaluation of human interactions with products and includes the analysis of user, environment and product complexity. Consideration of HF may mitigate known and potential hazards from the use and misuse of a consumer product, including e-cigarettes.

Methods

Five databases were searched through January 2014 and publications relevant to HF were incorporated. Voluntary adverse event (AE) reports submitted to the US Food and Drug Administration (FDA) and the package labelling of 12 e-cigarette products were analysed.

Results

No studies specifically addressing the impact of HF on e-cigarette use risks were identified. Most e-cigarette users are smokers, but data on the user population are inconsistent. No articles focused specifically on e-cigarette use environments, storage conditions, product operational requirements, product complexities, user errors or misuse.

Twelve published studies analysed e-cigarette labelling and concluded that labelling was inadequate or misleading. FDA labelling analysis revealed similar concerns described in the literature. AE reports related to design concerns are increasing and fatalities related to accidental exposure and misuse have occurred; however, no publications evaluating the relationship between AEs and HF were identified.

Conclusions

The HF impacting e-cigarette use and related hazards are inadequately characterised. Thorough analyses of user–product–environment interfaces, product complexities and AEs associated with typical and atypical use are needed to better incorporate HF engineering principles to inform and potentially reduce or mitigate the emerging hazards associated with e-cigarette products.

Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review

Electronic cigarettes are a recent development in tobacco harm reduction. They are marketed as less harmful alternatives to smoking. Awareness and use of these devices has grown exponentially in recent years, with millions of people currently using them. This systematic review appraises existing laboratory and clinical research on the potential risks from electronic cigarette use, compared with the well-established devastating effects of smoking tobacco cigarettes. Currently available evidence indicates that electronic cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to electronic cigarettes. Research will help make electronic cigarettes more effective as smoking substitutes and will better define and further reduce residual risks from use to as low as possible, by establishing appropriate quality control and standards.