Electronic Cigarette Device-Related Hazards:: A Call for Immediate FDA Regulation

Health outcomes of electronic cigarettes

ABSTRACT

The usage of electronic cigarettes (e-cigarettes) sparked an outbreak of unidentified vaping-related lung disease in the US during late 2019. With e-cigarettes becoming more and more popular, smokers have more options other than conventional cigarettes. Under these circumstances, a comprehensive evaluation of the general safety of new tobacco and tobacco-related products, represented by e-cigarettes, to human health is necessary. In this review, we summarize the current research on potential negative impacts of e-cigarette exposure on human health. In particular, studies detailing the relationship between e-cigarettes and the digestive system are summarized, with mechanisms mainly including hepatic metabolic dysfunction, impaired gut barrier, and worsened outcomes of inflammatory bowel disease (IBD). Although believed to be safer than traditional cigarettes, e-cigarettes exert adverse effects on systemic health and induce the development of multiple diseases including asthma, cardiovascular disease, and IBD. Moreover, nicotine-containing e-cigarettes have a negative impact on the childhood development and increase the risk of arterial stiffness compared to the non-nicotine e-cigarettes. However, non-nicotine e-cigarette components have detrimental effects including promoting liver damage and metabolic disorders.

Patterns of Daily Cigarette and E-cigarette Use among United States Youth and Young Adults: Insights from the Truth Longitudinal Cohort between 2018 and 2019

Purpose

Temporal patterns of daily tobacco product use among ever users from the Truth Longitudinal Cohort (TLC) between 2018 and 2019 were explored.

Methods

The sample (N = 5274) includes individuals (15-36 years), residing in the United States, who had ever used any tobacco product at Wave 7 (February - May 2018) and provided tobacco use information at Wave 9 (September - December 2019).

Results

There was a nonsignificant 1.1 percentage point increase in daily tobacco use (on at least 25 of the past 30 days), from 14.6% (95% CI: 12.8, 16.6) to 15.7% (95% CI: 13.8, 17.7). Tobacco product use remained stable over time, as 65.3% (95% CI: 56.4, 73.3) of daily cigarette smokers, 57.0% (95% CI: 43.6, 69.4) of daily e-cigarette vapers, and 8.5% (95% CI: 2.0, 29.3) of daily dual users stayed with their primary tobacco product. There was also some evidence of switching, as 7.5% (95% CI: 3.7, 14.8) of daily cigarette smokers became daily e-cigarette vapers and 2.3% (95% CI: 0.7, 6.8) of daily e-cigarette vapers became daily cigarette smokers.

Discussion

Although most daily tobacco users were likely to continue using their primary product, some daily users transitioned to daily use of other products - suggesting that policies and public education focused on reducing overall nicotine use are essential for addressing the nicotine epidemic among young people.

Occurrence of metals in e-cigarette liquids: Influence of coils on metal leaching and exposure assessment

Electronic cigarettes are generally recognized as a safer alternative than conventional cigarettes. Nevertheless, previous research suggests metal (loid) leaching due to coil contact, potentially transferring to the e-liquid and its aerosolized form. In this study, Cr, Cd, Ni, and Pb levels were measured by inductively coupled plasma mass spectrometry (ICP-MS) on 17 samples of e-liquids with different chemical properties (e.g., pH, nicotine content, flavoring, free-base, and nicotine salts). Twelve e-liquids were then put in contact with 36-gauge Kanthal A-1, Nichrome 80, Stainless steel 317 L and disposable coils such as Juul, and Aspire BVC for three days at 200-250 °C for 1 h each day. Metal levels expressed as mean (standard deviation) metal concentration, were below detection (Cd) to very low in bottle samples (Ni ≤ 76 (18); Pb ≤ 16 (1.5); and Cr ≤ 386 (15.6) μg/kg). In the coil extracts, varying concentrations of the same metal (loid) were found, indicating that metal leaching capacity may differ per sample. All samples contained Ni and Cr, followed by Pb to a much lesser extent. Cd levels were mostly below detection limits. Coil + e-liquid combinations with the highest Ni, Cr, and Pb concentrations were: Aspire BVC + Melon 0 mg/mL: Ni = 1.22 E+04 (281); Aspire BVC + Hit Nicotine 40 mg/mL: Cr = 864 (116); and Nichrome 80 + Melon 0 mg/mL: Pb = 56 (5) μg/kg. Overall, results suggest that nicotine salts at 40 mg/mL enhance Cr and Ni transfer. Stainless steel 317 L released very low metal concentrations. A conservative screening level risk characterization showed that 10.5% and 3.5% of the coil extracts may exceed Ni and Cr (III) safe concentrations, respectively. In the aerosol phase, 8.8% of samples might be above Ni equivalent daily dose for chronic exposure and 1.8% for intermediate exposure. Further studies on coil metal leaching could aid in establishing coil manufacturing regulations.

Young Adult JUUL Users' Beliefs About JUUL

PURPOSE

The purpose of this study was to test beliefs (risks to individual health, tobacco industry affiliation, and harm to others) with young adult current JUUL users to prompt decreased JUUL use.

METHODS

An explanatory sequential mixed-method design was used. Undergraduates aged 18-24 years at a large southwest university who owned and used a JUUL at least once a week completed an online survey (n = 667) in March 2019. Participant reactions to 6 JUUL-specific statements (harm to lungs and brain, tobacco industry ownership, communication device inside JUUL, harm to others and the environment) were assessed. Then, 51 participants completed an in-person interview 1-2 weeks later to explain what influenced their responses.

RESULTS

Across beliefs, females were more likely and those who used other tobacco products were less likely to say they would reduce JUUL use. Beliefs about harm to the brain, others, and the environment had the most influence on interview participants. Tobacco industry affiliation with JUUL was not viewed negatively and likely would not affect participant decisions.

CONCLUSIONS

Messaging developed for other tobacco products may not have the same impact with young adult JUUL users. These findings provide guidance to tobacco use regulators by informing marketing message regulations to prevent initiation or prolonged use of JUUL and other pod-based products.

[Where there´s smoke - there´s no fire? - Burns from E-Cigarette explosions]

INTRODUCTION

The popularity of E-Cigarettes is increasing. Besides addiction and pulmonary health damage, reports of burn injuries from e-cigarette explosions are also increasing. Mostly, explosions of e-cigarettes are attributed to its lithium-ion battery. Due to increasing cases and missing guidelines we want to present three cases of our hospital and publish recommendations for the management of burn injuries caused by e-cigarette explosions.

PATIENTS/MATERIAL AND METHODS

Three cases of e-cigarette explosions which occurred between 2016 and 2019, are presented.

RESULTS

All three e-cigarette explosions occurred in the trouser pockets. Two patients were male one patient was female. The age ranged from 24 to 64 years, the burned total body surface area (TBSA) from 3 % to 12.5 %. All three patients required skin grafting and the length of stay in hospital ranged from five to eleven days.

CONCLUSION

In the synopsis of recent literature, we recommend the following management of burns due to e-cigarette explosions. The guidelines of the Advanced Trauma Life Support should be followed, signs of an inhalation trauma should be checked and litmus test should be performed prior to irrigation with aqueous solutions to prevent exothermic reactions with remaining metals. If litmus test shows alkali pH wounds should be irrigated by mineral oil.

Metal/Metalloid Levels in Electronic Cigarette Liquids, Aerosols, and Human Biosamples: A Systematic Review

BACKGROUND

Electronic cigarettes (e-cigarettes) have become popular, in part because they are perceived as a safer alternative to tobacco cigarettes. An increasing number of studies, however, have found toxic metals/metalloids in e-cigarette emissions.

OBJECTIVE

We summarized the evidence on metal/metalloid levels in e-cigarette liquid (e-liquid), aerosols, and biosamples of e-cigarette users across e-cigarette device systems to evaluate metal/metalloid exposure levels for e-cigarette users and the potential implications on health outcomes.

METHODS

We searched PubMed/TOXLINE, Embase®, and Web of Science for studies on metals/metalloids in e-liquid, e-cigarette aerosols, and biosamples of e-cigarette users. For metal/metalloid levels in e-liquid and aerosol samples, we collected the mean and standard deviation (SD) if these values were reported, derived mean and SD by using automated software to infer them if data were reported in a figure, or calculated the overall mean (mean ± SD) if data were reported only for separate groups. Metal/metalloid levels in e-liquids and aerosols were converted and reported in micrograms per kilogram and nanograms per puff, respectively, for easy comparison.

RESULTS

We identified 24 studies on metals/metalloids in e-liquid, e-cigarette aerosols, and human biosamples of e-cigarette users. Metal/metalloid levels, including aluminum, antimony, arsenic, cadmium, cobalt, chromium, copper, iron, lead, manganese, nickel, selenium, tin, and zinc, were present in e-cigarette samples in the studies reviewed. Twelve studies reported metal/metalloid levels in e-liquids (bottles, cartridges, open wick, and tank), 12 studies reported metal/metalloid levels in e-cigarette aerosols (from cig-a-like and tank devices), and 4 studies reported metal/metalloid levels in human biosamples (urine, saliva, serum, and blood) of e-cigarette users. Metal/metalloid levels showed substantial heterogeneity depending on sample type, source of e-liquid, and device type. Metal/metalloid levels in e-liquid from cartridges or tank/open wicks were higher than those from bottles, possibly due to coil contact. Most metal/metalloid levels found in biosamples of e-cigarette users were similar or higher than levels found in biosamples of conventional cigarette users, and even higher than those found in biosamples of cigar users.

CONCLUSION

E-cigarettes are a potential source of exposure to metals/metalloids. Differences in collection methods and puffing regimes likely contribute to the variability in metal/metalloid levels across studies, making comparison across studies difficult. Standardized protocols for the quantification of metal/metalloid levels from e-cigarette samples are needed. https://doi.org/10.1289/EHP5686.

Differences in perceptions of e-cigarettes across daily and non-daily users

OBJECTIVE

E-cigarette use has increased significantly over the past decade. Among the growing population of e-cigarette users, several pattern-based subgroups have emerged, including daily and non-daily users. Daily users are at greater risk for experiencing negative health consequences from use. Yet, little is understood about underlying e-cigarette processes that may be related to daily use relative to non-daily use.

METHOD

The present study sought to investigate differences in three clinically-relevant e-cigarette processes, including perceived risks (including both absolute and comparable risks to combustible cigarettes), benefits, and innovation of e-cigarettes between daily and non-daily users. The study included 564 adult current e-cigarette users (51.1% female, M_age = 35.1 years, SD = 10.2).

RESULTS

Results indicated a significant difference in levels of perception for all three dependent variables, such that daily users reported a higher level of perceived risks, benefits, and innovation for e-cigarettes.

CONCLUSIONS

Overall, the current study provides empirical evidence that perceived risks, benefits and innovations may be more strongly endorsed by more daily e-cigarette uses. Importantly, this study adds to evolving, but thus far limited, knowledge of e-cigarettes by highlighting how frequency of e-cigarette use relates to beliefs about e-cigarette use.

Electronic cigarette explosion and burn injuries, US Emergency Departments 2015-2017

BACKGROUND

Electronic cigarette (e-cigarette) battery failure can result in explosions and burn injuries. Previous attempts to quantify these events has been limited to compilations of case studies, federal agency reports and media reports. Although e-cigarette explosions and burn injuries are thought to be rare, current surveillance methods likely underestimate actual occurrences.

METHODS

Analyses were conducted on cross-sectional data from the US Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS). A keyword search of case narrative text was used to identify e-cigarette-related explosion and burn injuries presenting to US emergency departments from 2015 to 2017. Sampling weights were applied to make conservative national incidence estimates.

RESULTS

From 2015 to 2017, there were an estimated 2035 e-cigarette explosion and burn injuries presenting to US hospital emergency departments (95% CI 1107 to 2964).

CONCLUSIONS

There are more e-cigarette explosion and burn injuries in the USA than estimated in the past reports. Improved surveillance of e-cigarette injuries and regulation of e-cigarette devices is urgently needed. NEISS could be a valuable resource for e-cigarette injury surveillance.

Electronic cigarettes—A review of the physiological health effects

Electronic cigarettes (ECs) are devices that are used recreationally or as smoking cessation tools, and have become increasingly popular in recent years. We conducted a review of the available literature to determine the health effects caused by the use of these devices. A heating element in the EC aerosolizes a solution of propylene glycol, glycerol, nicotine (optional), and flavouring (optional). These compounds are generally harmless on their own. However, upon heating, they produce various carcinogens and irritants. We found that concentrations of these toxicants vary significantly depending on the type of EC device, the type of EC liquid, and the smoking behaviour of the user. Exposure to these vapours can cause inflammation and oxidative damage to in vitro and in vivo cells. EC aerosol can also potentially affect organ systems and especially cardiovascular and lung function. We concluded that EC use causes acute effects on health but not as severe as those of conventional cigarettes (CCs). These devices could, therefore, be of use for smokers of CCs wishing to quit. However, as EC aerosol introduces new toxicants not found in CCs, long-term studies are needed to investigate possible chronic effects associated with EC use.