Assessing electronic cigarette emissions: linking physico-chemical properties to product brand, e-liquid flavoring additives, operational voltage and user puffing patterns

Perinatal nicotine vaping exposure induces pro-myofibroblastic phenotype in rat bone marrow-derived mesenchymal stem cells

Perinatal nicotine exposure via tobacco smoking results in increased proclivity to chronic lung disease (CLD); however, the underlying molecular mechanisms remain incompletely understood. We previously demonstrated that in addition to nicotine's direct effects on the developing lung, there are also adverse molecular alterations in bone marrow-derived mesenchymal stem cells (BMSCs), which are vital to lung injury repair. Whether perinatal nicotine exposure via electronic-cigarette (e-cig) vaping also adversely affects BMSCs is unknown. This is highly relevant due to marked increase in e-cig vaping including by pregnant women. Hypothesizing that perinatal nicotine exposure via e-cig vaping predisposes BMSCs to a pro-myofibroblastic phenotype, pregnant rat dams were exposed to fresh air (control), vehicle (e-cig without nicotine), or e-cig (e-cig with nicotine) daily during pregnancy and lactation. At postnatal day 21, offspring BMSCs were isolated and studied for cell proliferation, migration, wound healing response, and expression of key Wnt and PPARγ signaling intermediates (β-catenin, LEF-1, PPARγ, ADRP and C/EBPα) and myogenic markers (fibronectin, αSMA, calponin) proteins using immunoblotting. Compared to controls, perinatal e-cig exposure resulted in significant decrease in BMSC proliferation, migration, and wound healing response. The expression of key Wnt signaling intermediates (β-catenin, LEF-1) and myogenic markers (fibronectin, αSMA, calponin) increased significantly, while PPARγ signaling intermediates (PPARγ, ADRP, and C/EBPα) decreased significantly. Based on these data, we conclude that perinatally e-cig exposed BMSCs demonstrate pro-myofibroblastic phenotype and impaired injury-repair potential, indicating a potentially similar susceptibility to CLD following perinatal nicotine exposure via vaping as seen following parenteral perinatal nicotine exposure.

Composition of e-cigarette aerosols: A review and risk assessment of selected compounds

The potential harms and benefits of e-cigarettes, or electronic nicotine delivery systems (ENDS), have received significant attention from public health and regulatory communities. Such products may provide a reduced risk means of nicotine delivery for combustible cigarette smokers while being inappropriately appealing to nicotine naive youth. Numerous authors have examined the chemical complexity of aerosols from various open- and closed-system ENDS. This body of literature is reviewed here, with the risks of ENDS aerosol exposure among users evaluated with a margin of exposure (MoE) approach for two non-carcinogens (methylglyoxal, butyraldehyde) and a cancer risk analysis for the carcinogen N-nitrosonornicotine (NNN). We identified 96 relevant papers, including 17, 13, and 5 reporting data for methylglyoxal, butyraldehyde, and NNN, respectively. Using low-end (minimum aerosol concentration, low ENDS use) and high-end (maximum aerosol concentration, high ENDS use) assumptions, estimated doses for methylglyoxal (1.78 × 10-3-135 μg/kg-bw/day) and butyraldehyde (1.9 × 10-4-66.54 μg/kg-bw/day) corresponded to MoEs of 227-17,200,000 and 271-280,000,000, respectively, using identified points of departure (PoDs). Doses of 9.90 × 10-6-1.99 × 10-4 μg/kg-bw/day NNN corresponded to 1.4-28 surplus cancers per 100,000 ENDS users, relative to a NNN-attributable surplus of 7440 per 100,000 cigarette smokers. It was concluded that methylglyoxal and butyraldehyde in ENDS aerosols, while not innocuous, did not present a significant risk of irritant effects among ENDS users. The carcinogenic risks of NNN in ENDS aerosols were reduced, but not eliminated, relative to concentrations reported in combustible cigarette smoke.

Method Development and Validation of an Aerosol Sampling Technique for the Analysis of Nicotine in Electronic Cigarette Aerosols

Because of the increasing popularity of e-cigarettes, monitoring the e-cigarette market has become important for national health authorities to guarantee safety and quality. In the EU, the Tobacco Products Directive requires emission studies for e-cigarette products. The absence of industry guidelines for studying these emissions and the lack of proper validation in the literature led us to develop and validate a method using the total error approach for the determination of nicotine in e-cigarette aerosols. A commercial vaping device was used to generate aerosols, which were then collected on Cambridge filter pads and measured for nicotine concentration by UHPLC-DAD after extraction. The method was successfully validated by generating accuracy profiles, which show that the β-expectation tolerance intervals remained below the acceptance limits of ±20%. Within-run repeatability and intermediate precision were considered acceptable since the highest RSD value obtained was below 5%. The method was applied to 15 commercial e-liquids. A complete validation of a method for the analysis of e-cigarette emissions is presented, including several parameters that impact the accuracy and reproducibility. Similar systematic approaches for method development and validation could be used for other e-cigarette emission analysis methods to ensure the reliability of the measurements.

Examining the Oxidation States of Metals in Aerosols Emitted by Electronic Cigarettes

Electronic cigarettes (ECs) emit many toxic substances, including metals, that can pose a threat to users and the environment. The toxicity of the emitted metals depends on their oxidation states. Hence, this study examines the oxidation states of metals observed in EC aerosols. X-ray photoelectron spectroscopy analysis of the filters that collected EC aerosols identified the oxidation states of five primary metals (based on surface sample analysis), including chromium(III) (close to 100%) under low power setting while a noticeable amount of chromium(VI) (15%) at higher power settings of the EC, and copper(II) (100%), zinc(II) (100%), nickel(II) (100%), lead(II) (65%), and lead(IV) (35%) regardless of power settings. This observation indicates that the increased temperature due to higher power settings could alter the oxidation states of certain metals. We noted that many metals were in their lesser toxic states; however, inhaling these metals may still pose health risks.

Metal Concentrations in E-Cigarette Aerosol Samples: A Comparison by Device Type and Flavor

BACKGROUND

The rapid evolution of electronic cigarette (e-cigarette) products warrants surveillance of the differences in exposure across device types-modifiable devices (MODs), cartridge ("pod")-containing devices (PODs), disposable PODs (d-PODs)-and flavors of the products available on the market.

OBJECTIVE

This study aimed to measure and compare metal aerosol concentrations by device type and common flavors.

METHODS

We collected aerosol from 104 MODs, 67 PODs (four brands: JUUL, Bo, Suorin, PHIX), and 23 d-PODs (three brands: ZPOD, Bidi, Stig) via droplet deposition in a series of conical pipette tips. Metals and metalloids [aluminum (Al), arsenic (As), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), manganese (Mn), nickel (Ni), lead (Pb), antimony (Sb), tin (Sn), and zinc (Zn)] were measured using inductively coupled plasma mass spectrometry (ICP-MS), results were log-transformed for statistical analysis, and concentrations are reported in aerosol units (mg / m 3 ).

RESULTS

Of the 12 elements analyzed, concentrations were statistically significantly higher in MOD devices, except for Co and Ni, which were higher in PODs and d-PODs. Of the POD brands analyzed, PHIX had the highest median concentrations among four metals (Al, Ni, Pb, and Sn) compared to the rest of the POD brands. According to POD flavor, seven metals were three to seven orders of magnitude higher in tobacco-flavored aerosol compared to those in mint and mango flavors. Among the d-POD brands, concentrations of four metals (Al, Cu, Ni, and Pb) were higher in the ZPOD brand than in Bidi Stick and Stig devices. According to d-POD flavor, only Cr concentrations were found to be statistically significantly higher in mint than tobacco-flavored d-PODs.

DISCUSSION

We observed wide variability in aerosol metal concentrations within and between the different e-cigarette device types, brands, and flavors. Overall, MOD devices generated aerosols with higher metal concentrations than PODs and d-PODs, and tobacco-flavored aerosols contained the highest metal concentrations. Continued research is needed to evaluate additional factors (i.e., nicotine type) that contribute to metal exposure from new and emerging e-cigarette devices in order to inform policy. https://doi.org/10.1289/EHP11921.

The association of current exclusive e-cigarette use and dual use of e-cigarettes and cigarettes with psychological distress among U.S. adults

This observational study examines the association of current e-cigarette use and dual use of e-cigarettes and cigarettes (dual use) with psychological distress among U.S. adults. We differentiate dual use based on the smoking frequency and compare the relationship between dual use and psychological distress to that of exclusive cigarette smoking with the same smoking frequency. Using data from the 2015-2018 National Health Interview Surveys, we analyzed adults aged 18+ (N = 55,780) who currently use e-cigarettes or/and cigarettes and have no history of using other tobacco products, and adults who never used any tobacco. Multinomial logistic regression models estimate the association of current e-cigarette use and dual use with psychological distress severity (no/mild, moderate, and severe).In the sample, 15.3% and 2.9% of adults experienced moderate and severe psychological distress. Compared to never tobacco users, current exclusive e-cigarette users and dual users who smoke daily had higher odds of moderate and severe psychological distress. Dual users who smoke nondaily had higher odds of moderate, but not severe psychological distress than never tobacco users. Compared to exclusive daily smokers, dual users with daily smoking had higher odds of moderate and severe psychological distress. Compared to exclusive nondaily smokers, dual users with nondaily smoking had higher odds of moderate but not severe psychological distress. Our findings suggest that exclusive e-cigarette use is associated with psychological distress severity. Dual use is associated with higher odds of psychological distress severity compared to never tobacco users and exclusive cigarette smoking, and this association differs by smoking frequency.

Metals quantification in e-cigarettes liquids by Total Reflection X-ray Spectrometry

Electronic cigarettes (e-cig) have gained popularity around the world and its health risks demands more research. This study aims at characterizing e-cig liquids (e-liquids) and its constituents by Total Reflection X-ray Spectrometry (TXRF). The internal standard method was the quantification procedure employed. The spectrometer's performance was evaluated with one certified reference material and spiked samples. It was possible to quantify K, Ca, Ti, Cr, Mn, Fe, Ni, Cu, Zn, Br, and Pb in the e-liquids. Concentrations above the limit for potable water were found in 10 out of 38 samples. Principal component analysis was useful for identifying toxic samples. TXRF is a promising technique for e-liquids evaluation due to its simplicity and performance.

Preliminary toxicological assessment of heated tobacco products: A review of the literature and proposed strategy

Heated tobacco products (HTP) have become increasingly common in many countries worldwide. The principle of heating tobacco, without combustion, to produce a nicotine-containing aerosol with remarkably reduced levels of other known toxins, compared to combusted tobacco cigarettes, is now well established. As these products are intended as alternatives to traditional combusted products, during the early stages of their development, it is important for manufacturers to ensure that the design of the product does not lead to any unintentionally increased or new risk for the consumer, compared to the traditional products that consumers seek to replace. There is limited guidance from tobacco product regulations concerning the requirements for performing such preliminary toxicological assessments. Here, we review the published literature on studies performed on HTPs in the pursuit of such data, outline a proposed approach that is consistent with regulatory requirements, and provide a logical approach to the preliminary toxicological assessment of HTPs.

Exposure to secondhand aerosol from electronic cigarettes at homes: A real-life study in four European countries

Electronic cigarette (e-cigarette) use emits potentially hazardous compounds and deteriorates indoor air quality. Home is a place where e-cigarettes may frequently be used amid its increasing prohibition in public places. This study assessed the real-life scenario of bystanders' exposure to secondhand e-cigarette aerosol (SHA) at home. A one-week observational study was conducted within the TackSHS project in four countries (Greece, Italy, Spain, and the United Kingdom) in 2019 including: 1) homes of e-cigarette users living together with a non-user/non-smoker; and 2) control homes with no smokers nor e-cigarette users. Indoor airborne nicotine, PM2.5, and PM1.0 concentrations were measured as environmental markers of SHA. Biomarkers, including nicotine and its metabolites, tobacco-specific nitrosamines, propanediol, glycerol, and metals were measured in participants' saliva and urine samples. E-cigarette use characteristics, such as e-cigarette refill liquid's nicotine concentration, e-cigarette type, place of e-cigarette use at home, and frequency of ventilation, were also collected. A total of 29 e-cigarette users' homes and 21 control homes were included. The results showed that the seven-day concentrations of airborne nicotine were quantifiable in 21 (72.4 %) out of 29 e-cigarette users' homes; overall, they were quite low (geometric mean: 0.01 μg/m3; 95 % CI: 0.01-0.02 μg/m3) and were all below the limit of quantification in control homes. Seven-day concentrations of PM2.5 and PM1.0 in e-cigarette and control homes were similar. Airborne nicotine and PM concentrations did not differ according to different e-cigarette use characteristics. Non-users residing with e-cigarette users had low but significantly higher levels of cotinine, 3'-OH-cotinine and 1,2-propanediol in saliva, and cobalt in urine than non-users living in control homes. In conclusion, e-cigarette use at home created bystanders' exposure to SHA regardless of the e-cigarette use characteristics. Further studies are warranted to assess the implications of SHA exposure for smoke-free policy.

Chemical Elements, Flavor Chemicals, and Nicotine in Unused and Used Electronic Cigarettes Aged 5-10 Years and Effects of pH

The concentrations of elements/metals, nicotine, flavor chemicals and acids were compared in the e-liquids of unused and used first-generation electronic cigarettes (ECs) that were stored for 5-10 years. Metal analysis was performed using inductively coupled plasma optical emission spectroscopy; nicotine and flavor chemical analyses were performed using gas chromatography/mass spectroscopy. Of the 22 elements analyzed, 10 (aluminum, chromium, copper, iron, lead, nickel, selenium, silicon, tin, zinc) were often found in the e-liquids. Five elements had the highest average concentrations: copper (1161.6 mg/L), zinc (295.8 mg/L), tin (287.6 mg/L), nickel (71.1 mg/L), and lead (50.3 mg/L). Nicotine concentrations were always lower than label concentrations indicated. Of the 181 flavor chemicals analyzed, 11 were detected in at least one sample, with hydroxyacetone being present in all samples. In used products, some flavor chemicals appeared to be by-products of heating. E-liquids with the highest concentrations of acids and the lowest pH levels also had the highest concentrations of elements/metals. Metal concentrations in e-liquids increased after use in some products, and some metal concentrations, such as nickel, were high enough to be a health concern. Leachates from discarded ECs could contribute toxic metals/chemicals to the environment, supporting the need for better regulation of atomizer design, composition, and disposal.

Evidence for the coupling of refill liquids content and new particle formation in electronic cigarette vapors

The size and chemical content of particles in electronic cigarette vapors (e-vapors) dictate their fate in the human body. Understanding how particles in e-vapors are formed and their size is critical to identifying and mitigating the adverse consequences of vaping. Thermal decomposition and reactions of the refill liquid (e-liquid) components play a key role in new particles formation. Here we report the evolution of particle number concentration in e-vapors over time for variable mixtures of refill e-liquids and operating conditions. Particle with aerodynamic diameter < 300 nm accounted for up to 17% (or 780 μg/m³) of e-vapors particles. Two events of increasing particle number concentration were observed, 2-3 s after puff completion and a second 4-5 s later. The intensity of each event varied by the abundance of propylene glycol, glycerol, and flavorings in e-liquids. Propylene glycol and glycerol were associated with the first event. Flavorings containing aromatic and aliphatic unsaturated functional groups were strongly associated with the second event and to a lesser extent with the first one. The results indicate that particles in e-vapors may be formed through the heteromolecular condensation of propylene glycol, glycerol, and flavorings, including both parent chemicals and/or their thermal decomposition products.

E-cigarettes and their lone constituents induce cardiac arrhythmia and conduction defects in mice

E-cigarette use has surged, but the long-term health effects remain unknown. E-cigarette aerosols containing nicotine and acrolein, a combustion and e-cigarette byproduct, may impair cardiac electrophysiology through autonomic imbalance. Here we show in mouse electrocardiograms that acute inhalation of e-cigarette aerosols disturbs cardiac conduction, in part through parasympathetic modulation. We demonstrate that, similar to acrolein or combustible cigarette smoke, aerosols from e-cigarette solvents (vegetable glycerin and propylene glycol) induce bradycardia, bradyarrhythmias, and elevations in heart rate variability during inhalation exposure, with inverse post-exposure effects. These effects are slighter with tobacco- or menthol-flavored aerosols containing nicotine, and in female mice. Yet, menthol-flavored and PG aerosols also increase ventricular arrhythmias and augment early ventricular repolarization (J amplitude), while menthol uniquely alters atrial and atrioventricular conduction. Exposure to e-cigarette aerosols from vegetable glycerin and its byproduct, acrolein, diminish heart rate and early repolarization. The pro-arrhythmic effects of solvent aerosols on ventricular repolarization and heart rate variability depend partly on parasympathetic modulation, whereas ventricular arrhythmias positively associate with early repolarization dependent on the presence of nicotine. Our study indicates that chemical constituents of e-cigarettes could contribute to cardiac risk by provoking pro-arrhythmic changes and stimulating autonomic reflexes.

E-cigarette exposure with or without heating the e-liquid induces differential remodeling in the lungs and right heart of mice

Various cardiopulmonary pathologies associated with electronic cigarette (EC) vaping have been reported. This study investigated the differential adverse effects of heating-associated by-products versus the intact components of EC aerosol to the lungs and heart of mice. We further dissected the roles of caspase recruitment domain-containing protein 9 (CARD9)-associated innate immune response and NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome in EC exposure-induced cardiopulmonary injury. C57BL/6 wild type (WT), CARD9^-/-, and NLRP3^-/- mice were exposed to EC aerosol 3 h/day, 5 days/week for 6 month with or without heating the e-liquid with exposure to ambient air as the control. In WT mice, EC exposure with heating (EwH) significantly increased right ventricle (RV) free wall thickness at systole and diastole. However, EC exposure without heating (EwoH) caused a significant decrease in the wall thickness at systole. RV fractional shortening was also markedly reduced following EwH in WT and NLRP3^-/- mice. Further, EwH activated NF-κB and p38 MAPK inflammatory signaling in the lungs, but not in the RV, in a CARD9- and NLRP3-dependent manner. Levels of circulatory inflammatory mediators were also elevated following EwH, indicating systemic inflammation. Moreover, EwoH activated TGF-β1/SMAD2/3/α-SMA fibrosis signaling in the lungs but not the RV of WT mice. In conclusion, EC aerosol exposure following EwH or EwoH induced differential cardiopulmonary remodeling and CARD9 innate immune and NLRP3 inflammasome contributed to the adverse effects.

E-Cigarette (E-Cig) Liquid Composition and Operational Voltage Define the In Vitro Toxicity of Δ8Tetrahydrocannabinol/Vitamin E Acetate (Δ8THC/VEA) E-Cig Aerosols

The 2019 United States outbreak of E-cigarette (e-cig), or Vaping, Associated Acute Lung Injury (EVALI) has been linked to presence of vitamin E acetate (VEA) in Δ8tetrahydrocannabinol (Δ8THC)-containing e-liquids, as supported by VEA detection in patient biological samples. However, the pathogenesis of EVALI and the complex physicochemical properties of e-cig emissions remain unclear, raising concerns on health risks of vaping. This study investigates the effect of Δ8THC/VEA e-liquids and e-cig operational voltage on in vitro toxicity of e-cig aerosols. A novel E-cigExposure Generation System platform was used to generate and characterize e-cig aerosols from a panel of Δ8THC/VEA or nicotine-based e-liquids at 3.7 or 5 V. Human lung Calu-3 cells and THP-1 monocytes were exposed to cell culture media conditioned with collected e-cig aerosol condensate at doses of 85 and 257 puffs/m2 lung surface for 24 h, whereafter specific toxicological endpoints were assessed (including cytotoxicity, metabolic activity, reactive oxygen species generation, apoptosis, and inflammatory cytokines). Higher concentrations of gaseous volatile organic compounds were emitted from Δ8THC/VEA compared with nicotine-based e-liquids, especially at 5 V. Emitted PM2.5 concentrations in aerosol were higher for Δ8THC/VEA at 5 V and averagely for nicotine-based e-liquids at 3.7 V. Overall, aerosols from nicotine-based e-liquids showed higher bioactivity than Δ8THC/VEA aerosols in THP-1 cells, with no apparent differences in Calu-3 cells. Importantly, presence of VEA in Δ8THC and menthol flavoring in nicotine-based e-liquids increased cytotoxicity of aerosols across both cell lines, especially at 5 V. This study systematically investigates the physicochemical and toxicological properties of a model of Δ8THC/VEA and nicotine e-cigarette condensate exposure demonstrating that pyrolysis of these mixtures can generate hazardous toxicants whose synergistic actions potentially drive acute lung injury upon inhalation.

Examining Metal Contents in Primary and Secondhand Aerosols Released by Electronic Cigarettes

The usage of electronic cigarettes (ECs) has surged since their invention two decades ago. However, to date, the health effects of EC aerosol exposure are still not well understood because of insufficient data on the chemical composition of EC aerosols and the corresponding evidence of health risks upon exposure. Herein, we quantified the metals in primary and secondhand aerosols generated by three brands of ECs. By combining aerosol filter sampling and inductively coupled plasma mass spectrometry (ICP-MS), we assessed the mass of metals as a function of EC flavoring, nicotine concentration, device power, puff duration, and aging of the devices. The masses of Cr, Cu, Mn, Ni, Cu, and Zn were consistently high across all brands in the primary and secondhand aerosols, some of which were above the regulated maximum daily intake amount, especially for Cr and Ni with mass (nanograms per 10 puffs) emitted at 117 ± 54 and 50 ± 24 (JUUL), 125 ± 77 and 219 ± 203 (VOOPOO), and 33 ± 10 and 27 ± 2 (Vapor4Life). Our analysis indicates that the metals are predominantly released from the EC liquid, potentially through mechanisms such as bubble bursting or the vaporization of metal-organic compounds. High metal contents were also observed in simulated secondhand aerosols, generally 80-90% of those in primary aerosols. Our findings provide a more detailed understanding of the metal emission characteristics of EC for assessing its health effects and policymaking.

Assessing variability of aerosols generated from e-Cigarettes

While some in vitro and in vivo experiments have studied the toxic effects of e-cigarette (e-cig) components, the typical aerosol properties released from e-cigarettes have not been well characterized. In the present study, we characterized the variability in mass concentration and particle size distribution associated with the aerosol generation of different devices and e-liquid compositions in an experimental setup. The findings of this study indicate a large inter-day variability in the experiments, likely due to poor quality control in some e-cig devices, pointing to the need for a better understanding of all the factors affecting exposures in in vitro and in vivo experiments, and the development of standardized protocols for generation and measurement of e-cig aerosols.

Effects of e-liquid flavor, nicotine content, and puff duration on metal emissions from electronic cigarettes

Vaping is the action of inhaling and exhaling aerosols from electronic cigarettes. The aerosols contain various amounts of toxic chemicals, including metals. The purpose of this study was to evaluate factors that can influence metal levels, including flavor and nicotine content in the e-liquid, and puff duration. Aerosols were collected from both closed-system (cartridge-based) and open-system e-cigarettes using e-liquids with different flavors (fruit, tobacco, and menthol), nicotine content (0, 6, 24, and 59 mg/mL), and different puff durations (1, 2, and 4 s). The concentrations of 14 metals in the collected aerosols were measured using inductively coupled plasma mass spectroscopy. Aerosol concentrations of As, Fe, and Mn varied significantly among fruit, tobacco, and menthol flavors in both closed-system and open-system devices. Concentrations of Al, Fe, Sn, and U were significantly higher in tobacco or menthol flavored aerosols compared to fruit flavors in closed-system devices. Aerosol W levels were significantly higher in tobacco flavored aerosols compared to fruit flavors in open-system devices. Concentrations of As, Fe, and Mn were higher in tobacco flavored aerosols compared to menthol flavors in both types of devices. The median Pb concentration decreased significantly from 15.8 to 0.88 μg/kg when nicotine content increased from 0 to 59 mg/mL, and median Ni concentration was 9.60 times higher in aerosols with nicotine of 59 mg/mL compared to 24 mg/mL (11.9 vs. 1.24 μg/kg) for closed-system devices. No significant differences were observed in aerosol metal concentrations for different puff durations. Aerosol metal concentrations varied widely between different flavors and nicotine content but not by puff duration. Flavor and nicotine content of the e-liquid could be potential factors in metal emissions. Some elements showed higher concentrations under certain conditions, highlighting the urgent need of developing strict product regulations, especially on e-liquid composition and nicotine content to inform e-cigarette users about metal exposure through vaping.

E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs

"E-Cigarette (e-cig) Vaping-Associated Acute Lung Injury" (EVALI) has been linked to vitamin-E-acetate (VEA) and Δ-9-tetrahydrocannabinol (THC), due to their presence in patients' e-cigs and biological samples. Lacking standardized methodologies for patients' data collection and comprehensive physicochemical/toxicological studies using real-world-vapor exposures, very little data are available, thus the underlying pathophysiological mechanism of EVALI is still unknown. This review aims to provide a comprehensive and critical appraisal of existing literature on clinical/epidemiological features and physicochemical-toxicological characterization of vaping emissions associated with EVALI. The literature review of 161 medical case reports revealed that the predominant demographic pattern was healthy white male, adolescent, or young adult, vaping illicit/informal THC-containing e-cigs. The main histopathologic pattern consisted of diffuse alveolar damage with bilateral ground-glass-opacities at chest radiograph/CT, and increased number of macrophages or neutrophils and foamy-macrophages in the bronchoalveolar lavage. The chemical analysis of THC/VEA e-cig vapors showed a chemical difference between THC/VEA and the single THC or VEA. The chemical characterization of vapors from counterfeit THC-based e-cigs or in-house-prepared e-liquids using either cannabidiol (CBD), VEA, or medium-chain triglycerides (MCT), identified many toxicants, such as carbonyls, volatile organic compounds, terpenes, silicon compounds, hydrocarbons, heavy metals, pesticides and various industrial/manufacturing/automotive-related chemicals. There is very scarce published toxicological data on emissions from THC/VEA e-liquids. However, CBD, MCT, and VEA emissions exert varying degrees of cytotoxicity, inflammation, and lung damage, depending on puffing topography and cell line. Major knowledge gaps were identified, including the need for more systematic-standardized epidemiological surveys, comprehensive physicochemical characterization of real-world e-cig emissions, and mechanistic studies linking emission properties to specific toxicological outcomes.

Exhalation of alternative tobacco product aerosols differs from cigarette smoke-and may lead to alternative health risks

BACKGROUND

Variation in alternative tobacco product (ATP) constituents, heating potential, and consumer behaviors have made it difficult to characterize their health risks. To date, most toxicity studies of ATPs have used established cigarette endpoints to inform study design. Furthermore, to assess where ATPs fall on the tobacco harm continuum, with cigarettes representing maximum potential risk, studies have tended to compare the relative biological responses to ATPs against those due to cigarettes.

OBJECTIVES

1) To characterize the exhalation profiles of two popular ATPs: electronic cigarettes (e-cigarettes) and hookah waterpipes (hookah) and 2) to determine if ATP exhalation patterns were representative of cigarette exhalation patterns.

METHODS

Exhalation patterns were recorded (mouth only, nose only, or both mouth and nose) among individuals observed in the New York City tri-state area using a recognizable tobacco product (cigarette, e-cigarette, or hookah). Cigarette smokers and e-cigarette vapers were observed on city streets; water-pipe smokers were observed inside Manhattan hookah bars.

RESULTS

E-cigarette vapers practiced exclusive nasal exhalation at far higher rates than did cigarette smokers (19.5% vs 4.9%). Among vapers, e-cigarette device type was also significantly associated with exhalation profile. Overall, cigarette smokers exhaled from their nose approximately half to one-third as often as ATP users (hookah and e-cigarettes, respectively).

CONCLUSIONS

Nasal exhalation of tobacco emissions appears to be a shared characteristic across several types of ATPs. It is therefore plausible that ATP-specific consumer behaviors may foster unique upper respiratory health consequences that have not been observed in smokers. Thus, product-specific behaviors should inform the prioritization of biological endpoints used in studies evaluating ATP toxicity and health effects.

Fabrication and Validation of an Economical, Programmable, Dual-Channel, Electronic Cigarette Aerosol Generator

Vaping (inhalation of electronic cigarette-generated aerosol) is a public health concern. Due to recent spikes in adolescent use of electronic cigarettes (ECIGs) and vaping-induced illnesses, demand for scientific inquiry into the physiological effects of electronic cigarette (ECIG) aerosol has increased. For such studies, standardized and consistent aerosol production is required. Many labs generate aerosol by manually activating peristaltic pumps and ECIG devices simultaneously in a predefined manner. The tedium involved with this process (large puff number over time) and risk of error in keeping with puff topography (puff number, duration, interval) are less than optimal. Furthermore, excess puffing on an ECIG device results in battery depletion, reducing aerosol production, and ultimately, its chemical and physical nature. While commercial vaping machines are available, the cost of these machines is prohibitive to many labs. For these reasons, an economical and programmable ECIG aerosol generator, capable of generating aerosol from two atomizers simultaneously, was fabricated, and subsequently validated. Validation determinants include measurements of atomizer temperatures (inside and outside), electrical parameters (current, resistance and power) of the circuitry, aerosol particle distribution (particle counts and mass concentrations) and aerosol delivery (indexed by nicotine recovery), all during stressed conditions of four puffs/minute for 75 min (i.e., 300 puffs). Validation results indicate that the ECIG aerosol generator is better suited for experiments involving ≤100 puffs. Over 100 puffs, the amount of variation in the parameters measured tends to increase. Variations between channels are generally higher than variations within a channel. Despite significant variations in temperatures, electrical parameters, and aerosol particle distributions, both within and between channels, aerosol delivery remains remarkably stable for up to 300 puffs, yielding over 25% nicotine recovery for both channels. In conclusion, this programmable, dual-channel ECIG aerosol generator is not only affordable, but also allows the user to control puff topography and eliminate battery drain of ECIG devices. Consequently, this aerosol generator is valid, reliable, economical, capable of using a variety of E-liquids and amenable for use in a vast number of studies investigating the effects of ECIG-generated aerosol while utilizing a multitude of puffing regimens in a standardized manner.

ICP-MS Determination of 23 Elements of Potential Health Concern in Liquids of e-Cigarettes. Method Development, Validation, and Application to 37 Real Samples

The lack of interest in the determination of toxic elements in liquids for electronic cigarettes (e-liquids) has so far been reflected in the scarce number of accurate and validated analytical methods devoted to this aim. Since the strong matrix effects observed for e-liquids constitute an exciting analytical challenge, the main goal of this study was to develop and validate an ICP-MS method aimed to quantify 23 elements in 37 e-liquids of different flavors. Great attention has been paid to the critical phases of sample pre-treatment, as well as to the optimization of the ICP-MS conditions for each element and of the quantification. All samples exhibited a very low amount of the elements under investigation. Indeed, the sum of their average concentration was of ca. 0.6 mg kg-1. Toxic elements were always below a few tens of a μg per kg-1 and, very often, their amount was below the relevant quantification limits. Tobacco and tonic flavors showed the highest and the lowest concentration of elements, respectively. The most abundant elements came frequently from propylene glycol and vegetal glycerin, as confirmed by PCA. A proper choice of these substances could further decrease the elemental concentration in e-liquids, which are probably barely involved as potential sources of toxic elements inhaled by vapers.

Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography-High-Resolution Mass Spectrometry

The surge in electronic cigarette (e-cig) use in recent years has raised questions on chemical exposures that may result from vaping. Previous studies have focused on measuring known toxicants, particularly those present in traditional cigarettes, while fewer have investigated unknown compounds and transformation products formed during the vaping process in these diverse and constantly evolving products. The primary aim of this work was to apply liquid chromatography-high-resolution mass spectrometry (LC-HRMS) and chemical fingerprinting techniques for the characterization of e-liquids and aerosols from a selection of popular e-cig products. We conducted nontarget and quantitative analyses of tobacco-flavored e-liquids and aerosols generated using four popular e-cig products: one disposable, two pod, and one tank/mod. Aerosols were collected using a condensation device and analyzed in solution alongside e-liquids by LC-HRMS. The number of compounds detected increased from e-liquids to aerosols in three of four commercial products, as did the proportion of condensed-hydrocarbon-like compounds, associated with combustion. Kendrick mass defect analysis suggested that some of the additional compounds detected in aerosols belonged to homologous series resulting from decomposition of high-molecular-weight compounds during vaping. Lipids in inhalable aerosols have been associated with severe respiratory effects, and lipid-like compounds were observed in aerosols as well as e-liquids analyzed. Six potentially hazardous additives and contaminants, including the industrial chemical tributylphosphine oxide and the stimulant caffeine, were identified and quantified in the e-cig liquids and aerosols analyzed. The obtained findings demonstrate the potential of nontarget LC-HRMS to identify previously unknown compounds and compound classes in e-cig liquids and aerosols, which is critical for the assessment of chemical exposures resulting from vaping.

Environmental and individual exposure to secondhand aerosol of electronic cigarettes in confined spaces: Results from the TackSHS Project†

Secondhand electronic cigarette (e-cigarette) aerosol (SHA) might impair indoor air quality and expose bystanders. This study aims to investigate exposure to SHA in controlled conditions of enclosed settings simulating real-world scenario. An experiment was performed in a car and in a room, in which SHA was generated during a 30-minute ad libitum use of an e-cigarette. The experiment was replicated on five consecutive days in each setting. We measured PM_2.5 , airborne nicotine concentrations, and biomarkers of exposure to SHA, such as nicotine metabolites, tobacco-specific nitrosamines, propylene glycol, and glycerol in bystanders' saliva samples before, during, and after the exposure period. Self-reported health symptoms related to exposure to SHA were also recorded. The results showed that the highest median PM_2.5 concentration was recorded during the exposure period, being 21 µg/m³ in the room setting and 16 µg/m³ in the car setting-about twofold increase compared to the baseline. Most concentrations of the airborne nicotine and all biomarkers were below the limit of quantification in both settings. Bystanders in both settings experienced some short-term irritation symptoms, expressed as dry throat, nose, eyes, and phlegm. In conclusion, short-term use of an e-cigarette in confined spaces increased indoor PM_2.5 level and caused some irritation symptoms in bystanders.

The chemistry and toxicology of vaping

Vaping is the process of inhaling and exhaling an aerosol produced by an e-cigarette, vape pen, or personal aerosolizer. When the device contains nicotine, the Food and Drug Administration (FDA) lists the product as an electronic nicotine delivery system or ENDS device. Similar electronic devices can be used to vape cannabis extracts. Over the past decade, the vaping market has increased exponentially, raising health concerns over the number of people exposed and a nationwide outbreak of cases of severe, sometimes fatal, lung dysfunction that arose suddenly in otherwise healthy individuals. In this review, we discuss the various vaping technologies, which are remarkably diverse, and summarize the use prevalence in the U.S. over time by youths and adults. We examine the complex chemistry of vape carrier solvents, flavoring chemicals, and transformation products. We review the health effects from epidemiological and laboratory studies and, finally, discuss the proposed mechanisms underlying some of these health effects. We conclude that since much of the research in this area is recent and vaping technologies are dynamic, our understanding of the health effects is insufficient. With the rapid growth of ENDS use, consumers and regulatory bodies need a better understanding of constituent-dependent toxicity to guide product use and regulatory decisions.

Analytical methods for the identification of micro/nano metals in e-cigarette emission samples: a review

In this review, numerous analytical methods to quantify the heavy and trace elements emitted from electronic cigarettes, cigarettes liquid and atomizer. The selection of a method was dependent upon the purpose, e.g., quantification or identification of elements only. The introductory part of this review focuses on describing the importance of setting up an electronic cigarettes- associated safety profile. The review dealt with studies that assessed elements in sizes ranging from nano to micro. The formation of different degradation chemical substances as well as impurity trends can be indicated through chemical investigation of metals in electronic cigarettes. Some studies have been covered that show the uses and benefits of. It is noticeable from all the collected sources that the minerals emitted from the smoke of e- cigs do not constitute any significant damage, as the percentage is very small, with the exception of minerals that may be emitted from the components of the device after heating it if the components of the e- cig are of poor specifications, except in the case of long-term accumulation. For this reason, an electronic cigarette can help smokers to quit smoking tobacco and replace it with electronic cigarettes smoke with distinctive flavors.

Association of Cigarette Type Initially Smoked With Suicidal Behaviors Among Adolescents in Korea From 2015 to 2018

IMPORTANCE

Assessment of whether past electronic cigarette (e-cigarette) use or initiating smoking with e-cigarettes is associated with suicidal behaviors among adolescents is needed to inform future research and public health interventions.

OBJECTIVE

To evaluate the association between starting smoking with e-cigarettes or conventional cigarettes and suicidal behaviors among Korean adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data on adolescents in grades 7 through 12 who participated in the nationwide Korea Youth Risk Behavior Web-Based Survey between 2015 and 2018.

EXPOSURES

Type of cigarette initially smoked: electronic or conventional.

MAIN OUTCOMES AND MEASURES

Multiple logistic regression analysis was performed to examine the association between initial cigarette type and suicidal behaviors, including suicidal ideation and suicide planning and attempts. All participants completed questionnaires about their history of suicidal behavior and were categorized into groups according to the type of cigarette used at initiation of smoking and any subsequent change (or lack of change) in the type of cigarette used.

RESULTS

A total of 255 887 Korean adolescents (51.2% male; mean (SD) age, 15.0 [1.8] years) were included in the primary analysis. Among 131 094 male adolescents, 3310 boys (2.5%) initially used e-cigarettes and 27 368 boys (20.9%) initially used conventional cigarettes. Among 124 793 female adolescents, 952 girls (0.8%) initially used e-cigarettes and 9296 girls (7.4%) initially used conventional cigarettes. Of those who initially used e-cigarettes, 178 of 3310 boys (5.4%) and 134 of 952 girls (14.1%) attempted suicide. Of those who initially used conventional cigarettes, 946 of 27 368 boys (3.5%) and 911 of 9296 girls (9.8%) attempted suicide. Adolescents who initially used e-cigarettes had a higher risk of suicidal behaviors, including suicide planning (boys: adjusted odds ratio [AOR], 1.63 [95% CI, 1.40-1.89]; P < .001; girls: AOR, 1.55 [95% CI, 1.23-1.95]; P < .001) and suicide attempts (boys: AOR, 1.55 [95% CI, 1.28-1.87]; P < .001; girls, AOR, 1.64 [95% CI, 1.29-2.10]; P < .001) compared with those who initially used conventional cigarettes. Changing from e-cigarettes to conventional cigarettes was associated with a higher risk of suicide attempts among both boys (AOR, 1.89; 95% CI, 1.39-2.57; P < .001) and girls (AOR, 2.36; 95% CI, 1.53-3.64; P < .001) compared with changing from conventional cigarettes to e-cigarettes.

CONCLUSIONS AND RELEVANCE

In this study, the initial use of e-cigarettes vs conventional cigarettes was associated with suicidal behaviors among adolescents. In future research on the association of e-cigarette use with adolescent mental health and interventions for suicide prevention, the type of cigarette initially used and changing the cigarette type should be considered.

E-cigarette aerosol collection using converging and straight tubing Sections: Physical mechanisms

HYPOTHESIS

Identification and quantification of harmful chemicals in e-cigarette aerosol requires collecting the aerosolized e-liquid for chemical analysis. In 2016, Olmedo at al. empirically developed a simple method for aerosol collection by directing the aerosol through a sequence of alternating straight and converging tubing sections, which drain the recovered e-liquid into a collection vial. The tubing system geometry and flow conditions promote inertial impaction of aerosolized e-liquid on tube walls, where it deposits and flows into the collection vial.

EXPERIMENTS

We use high-speed optical imaging to visualize aerosol transport in proxies of the collection system. We also determined collection efficiencies of various configurations of the collection system.

FINDINGS

A turbulent jet emerges from converging conical sections and impinges onto the wall of downstream tubing sections, resulting in inertial impaction and deposition of the aerosol. For inertial impaction to occur the tip radius of the converging section must be small enough for a jet to be formed and the sequence of tubing sections must be curved in a polygon-like manner such that the jet emerging from a converging section impinges on the downstream tube wall. The collection efficiency is significantly smaller without such curvature.

A numerical investigation of the potential effects of e-cigarette smoking on local tissue dosimetry and the deterioration of indoor air quality

Electronic (e)-cigarette smoking is considered to be less harmful than traditional tobacco smoking because of the lack of a combustion process. However, e-cigarettes have the potential to release harmful chemicals depending on the constituents of the vapor. To date, there has been significant evidence on the adverse health effects of e-cigarette usage. However, what is less known are the impacts of the chemicals contained in exhaled air from an e-cigarette smoker on indoor air quality, the second-hand passive smoking of residents, and the toxicity of the exhaled air. In this study, we develop a comprehensive numerical model and computer-simulated person to investigate the potential effects of e-cigarette smoking on local tissue dosimetry and the deterioration of indoor air quality. We also conducted demonstrative numerical analyses for first-hand and second-hand e-cigarette smoking in an indoor environment. To investigate local tissue dosimetry, we used newly developed physiologically based pharmacokinetic/toxicokinetic models that reproduce inhalation exposure by way of the respiratory tract and dermal exposure through the human skin surface. These models were integrated into the computer-simulated person. Our numerical simulation results quantitatively demonstrated the potential impacts of e-cigarette smoking in enclosed spaces on indoor air quality.

A simple predictive model for estimating relative e-cigarette toxic carbonyl levels

E-cigarette devices are wide ranging, leading to significant differences in levels of toxic carbonyls in their respective aerosols. Power can be a useful method in predicting relative toxin concentrations within the same device, but does not correlate well to inter-device levels. Herein, we have developed a simple mathematical model utilizing parameters of an e-cigarette’s coil and wick in order to predict relative levels of e-liquid solvent degradation. Model 1, which is coil length/(wick surface area*wraps), performed in the moderate-to-substantial range as a predictive tool (R² = 0.69). Twelve devices, spanning a range of coil and wick styles, were analyzed. Model 1 was evaluated against twelve alternative models and displayed the best predictability. Relationships that included power settings displayed weak predictability, validating that power levels cannot be reliably compared between devices due to differing wicking and coil components and heat transfer efficiencies.

Chemical and Toxicological Characterization of Vaping Emission Products from Commonly Used Vape Juice Diluents

Recent reports have linked severe lung injuries and deaths to the use of e-cigarettes and vaping products. Nevertheless, the causal relationship between exposure to vaping emissions and the observed health outcomes remains to be elucidated. Through chemical and toxicological characterization of vaping emission products, this study demonstrates that during vaping processes, changes in chemical composition of several commonly used vape juice diluents (also known as cutting agents) lead to the formation of toxic byproducts, including quinones, carbonyls, esters, and alkyl alcohols. The resulting vaping emission condensates cause inhibited cell proliferation and enhanced cytotoxicity in human airway epithelial cells. Notably, substantial formation of the duroquinone and durohydroquinone redox couple was observed in the vaping emissions from vitamin E acetate, which may be linked to acute oxidative stress and lung injuries reported by previous studies. These findings provide an improved molecular understanding and highlight the significant role of toxic byproducts in vaping-associated health effects.

Method Validation Approaches for Analysis of Constituents in ENDS

OBJECTIVE

We assessed how many peer-reviewed publications reporting chemical quantities and/or yields from electronic nicotine delivery systems (ENDS) have included adequate method validation characteristics in the publication for appropriate interpretation of data quality for informing tobacco regulatory science.

METHODS

We searched 5 databases (Web of Knowledge, PubMed, SciFinder, Embase, EBSCOhost) for ENDS publications between January 2007 and September 2018. Of the 283 publications screened, 173 publications were relevant for analysis. We identified the publications that report a certain degree of control in data quality, ie, the publications that report marginally validated methods (MVMs). MVMs refer to the methods that: (1) report 3 or more International Conference on Harmonisation (ICH) method validation characteristics, (2) state the method was validated, (3) cite their own previous publication(s) that report MVMs, or (4) use a method within the accreditation scope of an accredited laboratory.

RESULTS

Overall, 97 publications (56%) report MVMs in their studies. This percentage also reflects the publication distribution for the majority of the 28 chemicals measured by MVMs.

CONCLUSIONS

This study highlights the need for reporting sufficient validation characteristics following appropriate guidance to ensure the accuracy and reliability of the published analytical data for proper data interpretations that may support policy.

E-cigarettes and respiratory health: the latest evidence

The E-cigarette market continues to expand at an alarming rate with thousands of flavours available for purchase and continuously evolving devices. Now that it is a multi-billion dollar industry and one without stringent regulation, there is rising concern over the safety of vaping products. Since June 2019, over 2800 cases of E-cigarette-associated acute lung toxicity have been reported in the USA, over 60 of which resulted in death. Many argue that E-cigarettes offer a safer alternative to smoking, but we are evidently far from fully understanding the potential hazards that they pose to respiratory health. Although the risk of an outbreak in the UK has been considered low due to tighter E-cigarette regulations, we cannot fully eliminate the possibility of similar events occurring in the future. With evidence frequently emerging of the harmful effects of E-cigarettes to pulmonary health, there is an urgent need to define the long-term implications of vaping. Studies show that E-cigarette exposure can disrupt pulmonary homeostasis, with reports of gas exchange disturbance, reduced lung function, increased airway inflammation and oxidative stress, downregulation of immunity, and increased risk of respiratory infection. In this review, the latest research on the effect of E-cigarette use on respiratory health will be presented.

Electronic nicotine delivery system design and aerosol toxicants: A systematic review

BACKGROUND

Electronic nicotine delivery systems (ENDS; e-cigarettes), consisting of a battery, heating element and e-liquid, have evolved significantly with wide variation in design, components, operating powers, and chemical constituents. Generated aerosols have been reported to contain potentially toxic substances. We conducted a systematic review to assess what is known about the presence of toxicants in ENDS aerosols in order to inform how system design could mitigate risk.

METHODS

Articles reporting on or evaluating design characteristics of ENDS and aerosol constituents were included and summarized.

RESULTS

The search identified 2,305 articles, of which 92 were included after full-text review. Findings were grouped into 6 major categories of potentially harmful chemicals: carbonyls, volatile organic chemicals, trace elements, reactive oxygen species and free radicals, polycyclic aromatic hydrocarbons, and tobacco-specific nitrosamines. In general, higher concentrations of aerosol toxicants are associated with increased power or voltage. Aerosol toxicants are also associated with e-liquid flavoring agents existing as primary ingredients or as products of thermal degradation.

CONCLUSIONS

Improved ENDS design can reduce toxicant levels. Additional research is needed to develop a framework for optimizing system characteristics to minimize exposure, especially with respect to heating power and e-liquids. Both manufacturers and regulatory agencies have roles in reducing toxicants and potential health risks from ENDS.

Effects of Electronic Cigarettes on Indoor Air Quality and Health

With the rapid increase in electronic cigarette (e-cig) users worldwide, secondhand exposure to e-cig aerosols has become a serious public health concern. We summarize the evidence on the effects of e-cigs on indoor air quality, chemical compositions of mainstream and secondhand e-cig aerosols, and associated respiratory and cardiovascular effects. The use of e-cigs in indoor environments leads to high levels of fine and ultrafine particles similar to tobacco cigarettes (t-cigs). Concentrations of chemical compounds in e-cig aerosols are generally lower than those in t-cig smoke, but a substantial amount of vaporized propylene glycol, vegetable glycerin, nicotine, and toxic substances, such as aldehydes and heavy metals, has been reported. Exposures to mainstream e-cig aerosols have biologic effects but only limited evidence shows adverse respiratory and cardiovascular effects in humans. Long-term studies are needed to better understand the dosimetry and health effects of exposures to secondhand e-cig aerosols.

Effects of Electronic Cigarettes on Indoor Air Quality and Health

With the rapid increase in electronic cigarette (e-cig) users worldwide, secondhand exposure to e-cig aerosols has become a serious public health concern. We summarize the evidence on the effects of e-cigs on indoor air quality, chemical compositions of mainstream and secondhand e-cig aerosols, and associated respiratory and cardiovascular effects. The use of e-cigs in indoor environments leads to high levels of fine and ultrafine particles similar to tobacco cigarettes (t-cigs). Concentrations of chemical compounds in e-cig aerosols are generally lower than those in t-cig smoke, but a substantial amount of vaporized propylene glycol, vegetable glycerin, nicotine, and toxic substances, such as aldehydes and heavy metals, has been reported. Exposures to mainstream e-cig aerosols have biologic effects but only limited evidence shows adverse respiratory and cardiovascular effects in humans. Long-term studies are needed to better understand the dosimetry and health effects of exposures to secondhand e-cig aerosols.

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.

Investigating E-Cigarette Particle Emissions and Human Airway Depositions under Various E-Cigarette-Use Conditions

E-cigarette use is dramatically increasing, particularly with adolescents. While the chemical composition of e-liquids and e-vapor is well characterized, the particle size distribution and the human airways deposition patterns of e-cigarette particles are understudied and poorly understood despite their likely contribution to adverse health effects from e-cigarette usage. In this study, we examined the impacts of e-cigarette device power, e-liquid composition, and vaping topography on e-cigarette particle sizes and their deposition in human airways. In addition, we observed that particle measurement conditions (dilution ratio, temperature, and humidity) significantly affect measured e-cigarette particle sizes. E-cigarette power output significantly increased particle count median diameters (CMD) from 174 ± 13 (particles generated under 6.4 W) to 236 ± 14 nm (particles generated under 31.1 W). E-cigarette particles generated from propylene glycol-based e-liquids (CMD = 145 ± 8 nm and mass median diameter [MMD] = 3.06 ± 0.17 μm) were smaller than those generated from vegetable glycerin-based e-liquids (CMD = 182 ± 9 nm and MMD = 3.37 ± 0.21 μm). Puff volume also impacted vapor particle size: CMD and MMD were 154 ± 11 nm and 3.50 ± 0.27 μm, 163 ± 6 nm and 3.35 ± 0.24 μm, and 146 ± 12 nm and 2.95 ± 0.14 μm, respectively, for 35, 90, and 170 mL puffs. Estimated e-cigarette particle mass deposition fractions in tracheobronchial and bronchoalveolar regions were 0.504-0.541 and 0.073-0.306, respectively. Interestingly, e-cigarette particles are smaller than the particles generated from cigarette smoking but have similar human airway deposition patterns.

Association Between e-Cigarette Use and Depression in the Behavioral Risk Factor Surveillance System, 2016-2017

IMPORTANCE

The prevalence of the use of electronic cigarettes (e-cigarettes) in the United States has grown rapidly since their introduction to the market more than a decade ago. While several studies have demonstrated an association between combustible cigarette smoking and depression, the association between e-cigarette use and depression has not been thoroughly studied.

OBJECTIVE

To examine the association between e-cigarette use and depression in a nationally representative sample of the adult population in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of the Behavioral Risk Factor Surveillance System database, 2016 to 2017. The Behavioral Risk Factor Surveillance System is the largest national telephone-based survey of randomly sampled adults in the United States. A total of 892 394 participants with information on e-cigarette use and depression were included. Data analysis was conducted in May 2019.

EXPOSURES

Electronic cigarette use status defined by self-report as never, former, or current use.

MAIN OUTCOMES AND MEASURES

Self-reported history of a clinical diagnosis of depression.

RESULTS

Of the 892 394 participants (414 326 [29.0%] aged ≥60 years; 502 448 [51.3%] women), there were 28 736 (4.4%) current e-cigarette users, of whom 13 071 (62.1%) were aged between 18 and 39 years. Compared with never e-cigarette users, current e-cigarette users were more likely to be single, male, younger than 40 years, and current combustible cigarette smokers (single, 120 797 [24.3%] vs 10 517 [48.4%]; men, 318 970 [46.6%] vs 14 962 [60.1%]; aged 18-39 years, 129 085 [32.2%] vs 13 071 [62.1%]; current combustible cigarette use, 217 895 [7.9%] vs 8823 [51.8%]). In multivariable adjusted models, former e-cigarette users had 1.60-fold (95% CI, 1.54-1.67) higher odds of reporting a history of clinical diagnosis of depression than never users, whereas current e-cigarette users had 2.10 (95% CI, 1.98-2.23) times higher odds. Additionally, higher odds of reporting depression were observed with increased frequency of use among current e-cigarette users compared with never users (daily use: odds ratio, 2.39; 95% CI, 2.19-2.61; occasional use: odds ratio, 1.96; 95% CI, 1.82-2.10). Similar results were seen in subgroup analyses by sex, race/ethnicity, smoking status, and student status.

CONCLUSIONS AND RELEVANCE

This study found a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use. If confirmed by other study designs, the potential mental health consequences may have regulatory implications for novel tobacco products.

Latent Class Analysis of E-cigarette Use Sessions in Their Natural Environments

BACKGROUND

Delivery of nicotine and substances from electronic nicotine delivery systems, or e-cigarettes, depends in part on how users puff on the devices. Little is known about variation in puffing behavior to inform testing protocols or understand whether puffing behaviors result in increased exposure to emissions.

METHODS

We analyzed puff topography data collected using a wireless portable use monitor (wPUM) continuously over 2 weeks among 34 current second-generation e-cigarette users in their everyday lives. For each puff, the wPUM recorded date, time, duration, volume, flow rate, and inter-puff interval.

RESULTS

We defined use session and classes at the session level using multilevel latent profile analysis, resulting in two session classes and three person types. Session class 1 ("light") was characterized by 14.7 puffs per session (PPS), low puff volume (59.9 ml), flow rate (28.7 ml/s), and puff duration (202.7 s × 100). Session class 2 ("heavy") was characterized by 16.7 PPS with a high puff volume (290.9 ml), flow rate (71.5 ml/s), and puff duration (441.1 s × 100). Person class 1 had almost exclusively "light" sessions (98.0%), whereas person class 2 had a majority of "heavy" sessions (60.7%) and person class 3 had a majority of "light" sessions (75.3%) but some "heavy" sessions (24.7%).

CONCLUSION

Results suggest there are different session topography patterns among e-cigarette users. Further assessment is needed to determine whether some users have increased exposure to constituents and/or health risks because of e-cigarettes.

IMPLICATIONS

Our study examines topography characteristics in a users' natural setting to identify two classes of e-cigarette session behavior and three classes of users. These results suggest that it is important for studies on the health effects of e-cigarettes to take variation in user topography into account. It is crucial to accurately understand the topography profiles of session and user types to determine whether some users are at greater exposure to harmful or potentially harmful constituents and risks from e-cigarettes as they are used by consumers.

Influence of the E-Cigarette Emission Profile by the Ratio of Glycerol to Propylene Glycol in E-Liquid Composition

The use of electronic cigarettes (E-cig) is popular because of the perception that they are less addictive and safer compared to the traditional cigarettes. Nevertheless, there are still harmful effects associated with chemicals emitted from E-cig. Identifying the sources of the emitted compounds can be challenging because of the differences in the design of E-cig devices and the variability in the composition of E-cig liquids used in these devices. In this study, the emission profiles from impurity-free E-liquids containing only propylene glycol and glycerol in various percentage ratios along with two commercially available E-liquids were evaluated using gas chromatography-mass spectrometry (GC-MS). This study approach allows the elucidation of the transformation pathways of the major emitted compounds without the confounding effects of existing impurities or flavor ingredients added to E-liquids. Analysis of the vapor phases of E-cig emissions detected toxicants such as acetaldehyde, acrolein, benzaldehyde, as well as benzene, toluene, ethylbenzene, and xylene (BTEX) compounds. The amount of glycerol in the E-liquids has a major effect on the concentration of these hazardous compounds emitted because the concentration of these chemicals increased with increasing glycerol percentage in the E-liquid. Acetaldehyde and acrolein increased by 175-fold and 28-fold, respectively, when the glycerol composition was increased from 0 to 80%. Benzaldehyde, naphthalene, diphenyl ether, and glycerol along with menthol and nicotine that were present in the commercial E-liquids were also detected in the aerosol condensates. The cascade impactor data on the distribution of the nicotine and menthol in different size fractions from >2.5 to <2.5 μm allow the estimates of the extent of toxicant deposition in different parts of the pulmonary system including the oropharynx region, the trachea as well as inside the alveoli and bronchioles. In summary, users of E-cig are exposed to harmful chemicals even if the E-liquids contain only propylene glycol and glycerol without flavorings, nicotine, or impurities. Furthermore, this study shows that E-liquids containing higher percentages of glycerol will produce higher levels of toxicants compared to E-liquids with similar percentages of propylene glycol. This finding has important implications to E-cigarette vendors and manufacturers, consumers, and regulatory agencies.

Metal concentrations in electronic cigarette aerosol: Effect of open-system and closed-system devices and power settings

BACKGROUND

Electronic cigarettes (E-cigarettes) generate aerosol containing metal contaminants. Our goals were to quantify aerosol metal concentrations and to compare the effects of power setting and device type (closed-system vs. open-system) on metal release.

METHODS

Aerosol samples were collected from two closed-system devices (a cigalike and pod) and two open-system devices (mods). Each open-system device was operated at three different power settings to examine the effect of device power on metal release. Concentrations of 14 metals in e-cigarette aerosol collected via droplet deposition were measured using inductively coupled plasma mass spectroscopy. Aerosol metal concentrations were reported as mass fractions (μg/kg) in the e-liquid.

RESULTS

For open-system device 1 (OD1), median arsenic (As), chromium (Cr), copper (Cu), iron (Fe), manganese (Mn), nickel (Ni), lead (Pb), antimony (Sb), tin (Sn), and zinc (Zn) concentrations increased 14, 54, 17, 30, 41, 96, 14, 81, 631, and 7-fold when the device power was increased from low (20 W) to intermediate (40 W) setting. When the power was further increased from intermediate (40 W) to high (80 W) setting, concentrations of As, Cr, Cu, Mn, Ni, and Sb did not change significantly. For open-system device 2 (OD2), Cr and Mn concentrations increased significantly when device power was increased from low (40 W) to intermediate (120 W) setting, and then decreased significantly when power was further increased from intermediate (120 W) to high (200 W) setting. Among the four devices, aerosol metal concentrations were higher for the open-system than the closed-system devices, except for aluminum (Al) and uranium (U). For Cr, median (interquartile range) concentrations (μg/kg) from the open-system devices were 2.51 (1.55, 4.23) and 15.6 (7.88, 54.5) vs. 0.39 (0.05, 0.72) and 0.41 (0.34, 0.57) for the closed-system devices. For Ni, concentrations (μg/kg) from the open-system devices were 793 (508, 1169) and 2148 (851, 3397) vs. 1.32 (0.39, 3.35) and 11.9 (10.7, 22.7) from the closed-system devices. Inhalation of 0% and 100% of samples from OD1, 7.4% and 88.9% from OD2 by typical e-cigarette users would exceed chronic minimum risk levels (MRL) of Mn and Ni, respectively. No MRL exceedance was predicted for the closed-system devices. A large fraction of users of OD1 (100%) and OD2 (77.8%) would be exposed to Ni levels higher than those from reference tobacco cigarette 3R4F.

CONCLUSIONS

Our findings suggest that power setting and device type affect metal release from devices to aerosol which would subsequently be inhaled by users. Metal concentrations from open-system devices first increased with device power, and then leveled off for most metals. Open-system devices generate aerosol with higher metal concentrations than closed-system devices. These findings inform tobacco regulatory science, policy makers and health professionals on potential metal health risks associated with e-cigarette use, design and manufacturing.

E-Cigarette Chemistry and Analytical Detection

The study of e-cigarette aerosol properties can inform public health while longer-term epidemiological investigations are ongoing. The determination of aerosol levels of known toxins, as well as of molecules with unknown inhalation toxicity profiles, affords specific information for estimating the risks of e-cigarettes and for uncovering areas that should be prioritized for further investigation.

Impact of Electronic Cigarette Aerosols on Pregnancy and Early Development

As the use of electronic cigarettes (e-cigs) continues to increase, especially among youth and pregnant women, so does the need for investigations into the effects of e-cig aerosols on prenatal development and early life. Herein, the most recent findings on the effects of e-cig aerosols during pregnancy and early life are reviewed. The results of these studies support the need for immediate action to further understand the potential harm that e-cigs may cause to pregnant women and their children. The effects of e-cigs is completely unknown in regards to human development. This review provides evidence that e-cigs may be harmful to early life development and that the use of e-cigs should be avoided during pregnancy.

Chronic exposure to e-cig aerosols during early development causes vascular dysfunction and offspring growth deficits

Increasing popularity of electronic cigarettes (e-cigs), including among women of reproductive age, is attributed to its perceived safety compared to conventional tobacco. However, there is a major knowledge gap surrounding the effects of e-cig aerosols on pregnancy and fetal development. We aimed to evaluate the effects of vaping e-cigs during gestation on offspring growth and to asses if growth deficits are accompanied by altered maternal and fetal vascular hemodynamics. Sprague-Dawley dams were assigned to Pair-Fed Control, Pair-Fed Juice, or Juice+Nicotine groups, and then underwent either a prenatal or prenatal+postnatal exposure paradigm in a custom-engineered vaping system. Mass spectrometry identified major aerosolized constituents from e-cig vaping. The Juice+Nicotine group exhibited significantly decreased fetal weight and crown-rump length (↓46.56%, and ↓23.83%, respectively). Pre- and postnatal exposure to Juice+Nicotine resulted in decreased pup weight at postnatal day (PND) 4-10. Crown-rump length was decreased by 24.71% on PND 10. Blood flow in the Juice+Nicotine group was decreased in the maternal uterine and fetal umbilical circuits by 49.50% and 65.33%, respectively. We conclude that chronic exposure to e-cig aerosols containing nicotine during early development can have deleterious health effects on the exposed offspring. Vaping e-cigs containing nicotine during pregnancy lead to a reduction in offspring weight and crown-rump length, associated with a marked decrease in blood flow in both the maternal uterine and fetal umbilical circulation (a strong indicator of growth restriction). Thus, chronic exposure to e-cig aerosols containing nicotine can lead to potentially harmful developmental effects in early life.

Composition and chemical health hazards of the most common electronic cigarette liquids in nine European countries

BACKGROUND

The aim of the present study was to identify the composition and reported chemical health hazards of the most common electronic cigarette liquids (e-liquids) in nine European Union (EU) Member States (MS) prior to adoption of the Tobacco Product Directive (TPD).

MATERIALS AND METHODS

Within the Horizon2020, EUREST-PLUS study, 122 of the most commonly sold e-liquids in 9 EU MS were randomly selected and purchased. A quantitative and qualitative chemical analysis was performed using a previously validated based gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry method. The most commonly detected compounds were then divided according to the Danger Globally Harmonized System of Classification and Labelling of Chemicals (GHS) and Warning GHS codes.

RESULTS

Within our qualitative analysis, 171 different compounds were detected. Discrepancies in measured versus reported nicotine concentration were identified. Forty-one (85.4%) of the most commonly detected compounds were registered with Warning GHS codes, 11 with Danger GHS codes and 9 with both codes. Of the total number of the detected compounds, 293 were attributable to fruits flavor, followed by tobacco flavor (204), nonalcoholic drinks (n = 64), desserts-sweets (n = 50), menthol - mint (n = 42) and alcohol (n = 39). Menthol which is classified as a strong irritant to skin and eye was the most frequently detected compound.

CONCLUSION

A large plethora of compounds with varying warning codes was identified in e-cigarette samples. The systematic monitoring and chemical evaluation of e-liquids are warranted, so as to ensure consumer protection.

Characteristics and correlates of electronic cigarette product attributes and undesirable events during e-cigarette use in six countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

This study assessed characteristics and correlates associated with e-cigarette product attributes and identified correlates of experiencing undesirable events during e-cigarette use among adult smokers across six European Union (EU) Members States (MS) prior to the implementation of the Tobacco Products Directive (TPD) in 2016.

METHODS

We conducted a cross-sectional survey with a nationally representative sample of adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) reporting e-cigarette use; randomly selected through a multistage cluster sampling design from June to September 2016. Stepwise logistic regressions were used to identify factors associated with use of flavors, noticing health warnings, mixing e-liquids, experiencing 'dry puff', e-liquid leaking during use and e-liquid spilling during refill.

RESULTS

Current daily or weekly prevalence of e-cigarette use among this sample of adult smokers was 7.5%. The most common attributes of e-cigarettes used included those that are flavored, contain nicotine, and are of tank style. Noticing health warnings on e-cigarette packaging and leaflets, respectively, was low (10.2% and 28%, respectively). Use of e-liquid refill nozzle caps, described as easy for a child to open, was associated with spilling during refill (OR=6.73; 95% CI: 2.02-22.37). Participants who adjusted occasionally or regularly the power (voltage) or temperature of their e-cigarette had greater odds of ever experiencing a 'dry puff' (OR=6.01; 95% CI: 2.68-13.46). Mixing different e-liquids was associated with leaking during use (OR=7.78; 95% CI: 2.45-24.73) and spilling during refill (OR=8.54; 95% CI: 2.29-31.88).

CONCLUSIONS

Ongoing evaluation of factors associated with e-cigarette attributes and of the correlates of experiencing e-cigarette undesirable events during use, related to product design, is crucial to monitoring the impact of the implementing Acts of the EU TPD.