Pesquisas sobre o vaping

Vaporaqui

O Vapor Aqui apresenta uma coletânea de pesquisas científicas realizadas ao redor do mundo à respeito do vaping / cigarros eletrônicos para servir como base para quem quer se manter informado sobre a realidade dos dispositivos, ao contrário do que é muitas vezes apresentado pela grande mídia.

Infelizmente a maioria dos artigos é em Inglês já que o país carece totalmente de pesquisas específicas na área.

Devido ao grande número de pesquisas, estamos organizando e traduzindo algumas informações, então a lista ainda não está finalizada.

Cigarros eletrônicos quando comparados com os comuns

2013 – O vapor dos cigarros eletrônicos é significativamente menos tóxico quando comparado com os cigarros comuns

Cytotoxicity evaluation of electronic cigarette (EC) vapor extract on cultured mammalian fibroblasts (ClearStream-LIFE): comparison with tobacco cigarette smoke (CS) extract (PDF 8 pages)


2014 – Os cigarros eletrônicos são muito menos prejudiciais que os cigarros comuns

Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette 

substitutes: a systematic review (PDF 20 páginas) 

Conclusão: “As evidências existentes indicam que o uso de cigarro eletrônico (CE) é de longe uma alternativa menos prejudicial ao fumo. Não há tabaco nem combustão envolvidos no uso de CE; portanto, vapers regulares podem evitar vários produtos químicos tóxicos prejudiciais que estão normalmente presentes na fumaça de cigarros de tabaco. De fato, alguns produtos químicos tóxicos também são liberados no vapor de CE, mas seus níveis são substancialmente mais baixos em comparação com a fumaça do tabaco e, em alguns casos (como as nitrosaminas), são comparáveis ​​às quantidades encontradas em produtos farmacêuticos de nicotina. Pesquisas, dados clínicos, químicos e toxicológicos têm sido freqüentemente deturpados ou mal interpretados pelas autoridades de saúde e reguladores do tabaco, de tal forma que o potencial para consequências prejudiciais do uso de CE tem sido amplamente exagerado. É óbvio que algum risco residual associado ao uso de CE pode estar presente, mas isso é provavelmente trivial em comparação com as consequências devastadoras do tabagismo. Além disso, os CEs são recomendados apenas para fumantes ou ex-fumantes, como substitutos dos cigarros convencionais ou para prevenir a recaída do tabagismo; assim, qualquer risco deve ser estimado em relação ao risco de continuar ou voltar a fumar e a baixa eficácia dos medicamentos atualmente aprovados para parar de fumar deve ser levada em consideração … ”


2014: Levels of selected carcinogens and toxicants in vapor from electronic cigarettes (PDF 16 pages) 

  • Results: The levels of potentially toxic compounds in e-cigarette vapor is from 9 to 450-fold lower than those in the smoke from conventional cigarettes, and in many cases comparable to the trace amounts present in pharmaceutical preparation (Note: Reference product was a medicinal nicotine inhaler.). Our findings support the idea that substituting tobacco cigarettes with electronic cigarettes may substantially reduce exposure to tobacco-specific toxicants.

2014: Evaluation of Toxicant and Carcinogen Metabolites in the Urine of E-Cigarette Users 

Versus Cigarette Smokers  (PDF 6 pages) 

  • Conclusion: “With respect to the compounds analyzed here, e-cigarettes have a more favorable toxicity profile than tobacco cigarettes.”

2015: Development of an in vitro cytotoxicity model for aerosol exposure using 3D reconstructed human airway tissue; application for assessment of e-cigarette aerosol (PDF 11 pages)

  • Despite being tested with a more intense puffing regime, e-cigarette aerosol showed no acute cytotoxicity in this study when compared with traditional 3R4F reference cigarette smoke.
  • Under the study conditions cigarette smoke demonstrated a dose-dependent response that resulted in near-complete cell death after a 6 h exposure period. In contrast, e-cigarette aerosol showed no decrease in tissue viability following a 6 h exposure, despite appropriate positive control responses. Furthermore, cytotoxicity appears to be unaffected by different e-cigarette formulations as tested in this study.

2016: Royal College of Physicians – Nicotine without Smoke (PDF 206 pages) 

  • Provision of the nicotine that smokers are addicted to without the harmful components of tobacco smoke can prevent most of the harm from smoking.
  • E-cigarettes are marketed as consumer products and are proving much more popular than NRT as a substitute and competitor for tobacco cigarettes.
  • E-cigarettes appear to be effective when used by smokers as an aid to quitting smoking.
  • The hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.
  • In the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking…

2016: A randomised, parallel group study to evaluate the safety profile of an electronic vapour product over 12 weeks (PDF 14 pages)

  • Conclusion: “In this study, we have demonstrated that no clinically relevant, product-related safety findings were observed for smokers of Combustible Cigarettes (CCs) switching to an Electronic Vapor Product (EVP) for 12 weeks under real-life settings. AEs reported by subjects switching to the EVP occurred primarily within the first week after switching, and only 1.3% of all AEs reported were considered to be almost definitely related to the product. Up to a third of all reported AEs in the EVP group were related to nicotine withdrawal symptoms, which were observed to decrease after the first two weeks from product switch. EVP use was associated with significant decreases in exposure to nicotine and other chemicals such as benzene and acrolein, typically found in CC smoke. Changes were also observed in the level of WBC, haemoglobin, RBC and LDL cholesterol, which although minor, were consistent with those observed after smoking cessation. The data presented in this study shows the potential that EVPs may offer to smokers looking for an alternative to CCs.”

2016: Exposure to Nicotine and Selected Toxicants in Cigarette Smokers Who Switched to 

Electronic Cigarettes: A Longitudinal Within-Subjects Observational Study 

(PDF 8 pages)

  • Conclusion: After switching from tobacco to e-cigarettes, nicotine exposure remains unchanged, while exposure to selected carcinogens and toxicants is substantially reduced.” 

2016: Tobacco Consumption and Toxicant Exposure of Cigarette Smokers Using Electronic 

Cigarettes (PDF  28 pages)

  • Smokers using ECs over 4 weeks maintained cotinine levels and experienced significant reductions in carbon monoxide, NNAL, and two out of eight measured VOC metabolites. Those who switched exclusively to ECs for at least half of the study period significantly reduced two additional VOCs.

2016: Reductions in biomarkers of exposure, impacts on smoking urge and assessment of product use and tolerability in adult smokers following partial or complete substitution of cigarettes with electronic cigarettes  (PDF 16 pages)

  • Subjects switching to e-cigarettes had significantly lower levels (29 %–95 %) of urinary BoEs after 5 days. Nicotine equivalents declined by 25 %–40 %. 
  • Dual users who substituted half of their self-reported daily cigarette consumption with e-cigarettes experienced 7 %–38 % reductions, but had increases (1 %–20 %) in nicotine equivalents. 
  • Blood nicotine biomarker levels were lower in the cessation (75 %–96 %) and e-cigarette use groups (11 %–83 %); dual users had no significant reductions. 
  • All groups experienced significant decreases in exhaled CO (27 %–89 %). Exhaled NO increases (46 %–63 %) were observed in the cessation and e-cigarette use groups; dual users had minimal changes. 
  • By Day 5, all groups had greater reductions in smoking urge compared to cessation. However, reductions were larger in the dual use group. 
  • No serious adverse events were observed.

2016: The mutagenic assessment of an electronic-cigarette and reference cigarette smoke using the Ames assay in strains TA98 and TA100 (PDF 10 pages)

  • In the presence and absence of metabolic activation, e-cigarette ACM and aerosol were deemed non-mutagenic in tester strains TA98 and TA100, under the test conditions described previously, despite clear positive control responses. Conversely, 3R4F cigarette smoke TPM and freshly generated whole smoke were clearly positive. 
  • In the case of freshly generated cigarette smoke, a positive response in both strains was observed within 24 min, whereas e-cigarette aerosols remained negative up to 3 h.

2016: Electronic cigarette aerosol induces significantly less cytotoxicity than tobacco smoke (PDF 16 pages)

  • Under the conditions tested, Vype ePen e-cigarette aerosol was significantly less cytotoxic than reference 3R4F cigarette smoke. 

2017: Comparing the cancer potencies of emissions from vapourised nicotine products 

including e-cigarettes with those of tobacco smoke (PDF 8 pages) 

  • “Most e-cigarette analyses indicate cancer potencies <1% that of tobacco smoke and <10% that of a heat-not-burn prototype, although a minority of analyses indicate higher potencies.”
  • Optimal combinations of device settings, liquid formulation and vaping behaviour normally result in e-cigarette emissions with much less carcinogenic potency than tobacco smoke.
  • Article in Lung Disease News: E-Cigarettes Carry Much Less Risk of Lung Cancer Than Cigarette Smoke, Study Finds 

2017: Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine 

Replacement Therapy Users: A Cross-sectional Study (PDF 15 pages)

  • Conclusion: “Former smokers with long-term e-cigarette–only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette–only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.” 

2017: Trace Metals Derived from Electronic Cigarette (ECIG) Generated Aerosol: Potential 

Problem of ECIG Devices That Contain Nickel (PDF 17 pages) 

  • In general, the findings of this study suggest that the concentrations of most trace metals extracted from cigarette smoke exceed the concentrations of trace metals extracted from ECIG-generated aerosol. 
  • Only Ni in the ECIG-generated aerosol was higher than control (smoke). The most probable source of Ni in this aerosol is the core assembly.
  • From this study, it is unlikely that the ECIG-generated aerosol contains enough of the other trace metals to induce significant pathology.

2017: Have combustible cigarettes met their match? The nicotine delivery profiles and harmful constituent exposures of second-generation (G2) and third-generation (G3) electronic cigarette users (PDF 6 pages)

  • While not harmless, electronic cigarettes (e-cigarettes) have demonstrated a much more favourable toxicological profile than combustible cigarettes—the worldwide leading cause of preventable death. Average eCO levels (ppm) were significantly higher in smokers than in e-cigarette users. Compared with cigarettes, G2 and G3 e-cigarettes resulted in significantly lower levels of exposure to a potent lung carcinogen and cardiovascular toxicant.

2017: E-cigarettes emit very high formaldehyde levels only in conditions that are aversive to users: A replication study under verified realistic use conditions (PDF 20 pages)

  • In realistic conditions, formaldehyde in e-cigarettes is lower than cigarette smoke
  • The high levels of formaldehyde emissions that were reported in a previous study were caused by unrealistic use conditions that create the unpleasant taste of dry puffs to e-cigarette users and are thus avoided.
  • The study shows the critical need to verify that realistic use conditions are tested in laboratory studies of e-cigarette emissions. This would ensure that abuse of devices in the laboratory setting is avoided and that findings have clinical relevance and represent realistic exposure of e-cigarette users. 

2017: Comparative tumor promotion assessment of e‐cigarette and cigarettes using the in vitro Bhas 42 cell transformation assay (PDF 9 pages)

  • Results from this study suggest that e‐cigarettes may have reduced tumor promoter activity compared to conventional cigarettes and therefore may provide a safer alternative to cigarettes.

2017: Benzene formation in electronic cigarettes (PDF 10 pages)

  • The risks from benzene will be lower from e-cigarettes than from conventional cigarettes.

2018: NASEM report on E-Cig Health Effects evaluates the available evidence of health effects 

related to the use of E-cigarettes: Public Health Consequences of E-Cigarettes (750 pages)   Report At A Glance 

Comparisons of using e-cigarettes vs smoking:

  • There is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.
  • There is substantial evidence that except for nicotine, under typical conditions of use, exposure to potentially toxic substances from e-cigarettes is significantly lower compared with combustible tobacco cigarettes.
  • There is substantial evidence that completely switching from regular use of combustible tobacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems.
  • There is moderate evidence that risk and severity of dependence are lower for e-cigarettes than combustible tobacco cigarettes.
  • There is moderate evidence from randomized controlled trials that e-cigarettes with nicotine are more effective than e-cigarettes without nicotine for smoking cessation.
  • While the overall evidence from observational trials is mixed, there is moderate evidence from observational studies that more frequent use of e-cigarettes is associated with an increased likelihood of cessation.
  • There is moderate evidence that second-hand exposure to nicotine and particulates is lower from e-cigarettes compared with combustible tobacco cigarettes. 
  • There is limited evidence for improvement in lung function and respiratory symptoms among adult smokers with asthma who switch to e-cigarettes completely or in part (dual use).
  • There is limited evidence for reduction of chronic obstructive pulmonary disease (COPD) exacerbations among adult smokers with COPD who switch to e-cigarettes completely or in part (dual use).
  • There is limited evidence suggesting that switching to e-cigarettes will improve periodontal disease in smokers.

2018: Comparison of Nicotine and Toxicant Exposure in Users of Electronic Cigarettes and 

Combustible Cigarettes   (PDF 16 Pages)

  • Findings: “In this population-based cohort study of 5105 participants, current exclusive e-cigarette users had greater concentrations of biomarkers of nicotine, tobacco-specific nitrosamines, volatile organic compounds, and metals compared with never tobacco users. However, these concentrations were lower than those observed in current exclusive cigarette smokers and dual users of both products.” 

2018: Measurements of electronic cigarette-generated particles for the evaluation of lung cancer 

risk of active and passive users (PDF 23 pages)

  • Conclusion: In this study, we have demonstrated that no clinically relevant, product-related safety findings were observed for smokers of Combustible Cigarettes (CC) switching to an Electronic Vapor Product (EVP) for 12 weeks under real-life settings. Adverse Effects (AEs) reported by subjects switching to the EVP occurred primarily within the first week after switching, and only 1.3% of all AEs reported were considered to be almost definitely related to the product. Up to a third of all reported AEs in the EVP group were related to nicotine withdrawal symptoms, which were observed to decrease after the first two weeks from product switch. EVP use was associated with significant decreases in exposure to nicotine and other chemicals such as benzene and acrolein, typically found in CC smoke. Changes were also observed in the level of WBC, haemoglobin, RBC and LDL cholesterol, which although minor, were consistent with those observed after smoking cessation. The data presented in this study shows the potential that EVPs may offer to smokers looking for an alternative to CCs.” 

2018: Chemical Composition of myblu™ Pod-System E-Cigarette Aerosols: A Quantitative Comparison with Conventional Cigarette Smoke (PDF 1 page)

  • Testing of the myblu™ aerosols indicate low or no detectable levels of the toxicants tested. Over all the e-cigarettes yielded <1μg/puff of the toxicants tested compared to the reported cigarette yield of 381μg/puff. Of the 51 toxicants tested, eight were detected in the e-cigarette aerosols but at substantially lower levels than reported in cigarette smoke.
  • Findings from several recent clinical studies indicate that smokers who have switched to e-cigarettes have significantly lower exposure to carcinogens and toxicants found in cigarette smoke, with reductions largely indistinguishable from complete smoking cessation or use of licensed nicotine replacement products

2018: Carbonyl emissions from a novel heated tobacco product (IQOS): comparison with an e-cigarette and a tobacco cigarette (PDF 24 pages)

  • The IQOS heated tobacco product emits substantially lower levels of carbonyls than a commercial tobacco cigarette but higher levels than an e-cigarette. 

2018: The American Cancer Society Public Health Statementon Eliminating Combustible Tobacco Use in theUnited States (PDF 6 pages)

  • Many consumers are misinformed about the harms of electronic nicotine delivery systems (ENDS).
  • Many adults believe, erroneously, that ENDS are as harmful as combustible tobacco products,and the level of public understanding has deteriorated over time. In 2012, only11.5% of respondents to a national survey held this view. By 2015, 35.7% of respondents mistakenly believed that the harm associated with electronic cigarettes (e-cigarettes) was “about the same” as that of smoking conventional cigarettes.
  • Thus, public misunderstanding underscores the urgent need for consumer education about the absolute and relative risks posed by different tobacco products and to reinvigorate smokers’ understanding of the importance of quitting combustible tobacco.
  • Although the long-term effects of ENDS are not known, current-generation ENDS are markedly less harmful than combustible tobacco products
  • Some early evidence suggests that e-cigarettes may help some smokers reduce or quit combustible tobacco use.

2020: Association of electronic cigarette use with lead, cadmium, barium, and antimony body burden: NHANES 2015-2016 (PDF  23 pages)

  • Blood lead levels, and urinary cadmium, barium, and antimony levels were similar between participants who used e-cigarettes and participants who did not.
  • However, participants with a smoking history were more likely to have higher blood lead and urinary cadmium than participants who neither used e-cigarettes nor cigarettes.

2020: Comparison of the chemical composition of aerosols from heated tobacco products, electronic cigarettes and tobacco cigarettes and their toxic impacts on the human bronchial epithelial BEAS-2B cells (PDF 12 pages)

  • We first report that HTP (Heated Tobacco Product) delivers slightly less nicotine and emits much lower amounts of carbonyl and PAH compounds than tobacco cigarettes.
  • However, HTP emissions still contain carcinogenic compounds (e.g. formaldehyde, acetaldehyde and benzo[a]pyrene) and the amounts of carbonyls and PAHs in HTP aerosols are higher than in e-cig vapours.
  • In accordance with the levels of toxic compounds in each aerosol, HTP aerosol exhibits reduced cytotoxicity compared to cigarette smoke but higher than e-cig vapours. 
  • HTP and e-cig have the potential to increase oxidative stress and inflammatory response, in a manner very similar to that of cigarette smoke, but only after a more intensive exposure. In addition, our data support that e-cig use at higher power settings emit higher carbonyl and PAH compounds and, consequently, generate more oxidative stress.
  • Finally, this study contributes to a better understanding of HTP and e-cig emission properties and their related toxicological impacts and provides important data needed for risk assessment purposes, by demonstrating that HTP might be less harmful than tobacco cigarettes but considerably more harmful than e-cig. 

2020: Five-Day Changes in Biomarkers of Exposure Among Adult Smokers After Completely Switching From Combustible Cigarettes to a Nicotine-Salt Pod System (PDF 9 pages)

  • The results of this study concorded with evidence that complete switching from combustible cigarettes to vapor products may reduce exposure to key carcinogens and other toxicants known to be associated with tobacco-related diseases. 

E-cigarettes (without comparison to other products)

2013: Electronic Cigarettes: A Short Review   (PDF 6 pages) 

  • From our review of the literature and bearing in mind the long experience with theatrical mists, the short-term toxicity can be considered to be very low
  • Many smokers see the e-cigarette as a good way to quit smoking

2014 Peering through the mist: systematic review of what the chemistry of contaminants in 

electronic cigarettes tells us about health risks  (PDF 14 pages)

  • Threshold Limit Values (TLVs), were conducted under “worst case” assumptions about both chemical content of aerosol and liquids as well as behavior of vapers.
  • There was no evidence of potential for exposures of e-cigarette users to contaminants that are associated with risk to health at a level that would warrant attention if it were an involuntary workplace exposures.
  • Current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces. However, the aerosol generated during vaping as a whole (contaminants plus declared ingredients) creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep any adverse health effects as low as reasonably achievable.
  • Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.

2016: Characterization of potential impurities and degradation products in electronic cigarette formulations and aerosols (PDF 11 pages)

  • Most potential impurities or degradation products were not detectable.
  • Impurities or degradation products found were below occupational exposure limits.

2018 Metal emissions from e-cigarettes: a risk assessment analysis of a recently-published 

study (PDF 7 pages)

  • EC emissions contain trace levels of metals. For almost all metals, unrealistically high levels of liquid need to be consumed in order for total daily exposure to exceed established limits.

Flavors

2015 An approach to ingredient screening and toxicological risk assessment of flavours 

in e-liquids (PDF is 9 pages)

  • Individual flavours or groups of flavours were added to the tobacco rod and the resultant smoke was analysed for priority smoke constituents and tested in several in vitro tests as well as 90-day rat inhalation studies. In general, addition of the flavours had no effect on, or reduced the levels of most of the measured smoke constituents.”

2018: Do flavouring compounds contribute to aldehyde emissions in e-cigarettes? (PDF 27 pages)

  • Aldehyde emissions from all flavoured liquids were 79–99.8% lower than smoking and lower than commonly measured indoor levels and occupational and indoor safety limits.

2019 Toxicity classification of e-cigarette flavouring compounds based on European Union 

regulation: analysis of findings from a recent study (PDF 8 pages) 

  • The vast majority of flavouring compounds in e-cigarette liquids as reported in a recent study were present at levels far lower than needed to classify them as toxic. 

2019: High Content Screening in NHBE cells shows significantly reduced biological activity of flavoured e-liquids, when compared to cigarette smoke condensate (PDF 11 pages)

  • Our results clearly show a lower toxicity of e-liquids, including flavoured e-liquids, when compared to CSC (cigarette smoke condensate). Typically, more than 100 times higher concentrations of CFs (Base liquids, with or without nicotine, and commercial, flavoured, nicotine-containing e-liquids) are required to elicit the same response as those observed for 3R4F CSC in specific endpoints.
  • Flavours play a critical role in attracting, and retaining smokers to e-cigarettes.

PG / VG / Nicotine

2006: United States Environmental Protection Agency:  Reregistration Eligibility Decision (RED)  for propylene glycol and dipropylene glycol (79 pages) 

  • Air Sanitizer: Read the directions included with the automatic dispenser for proper installation of unit and refill. Remove cap from aerosol can and place in a sequential aerosol dispenser which automatically releases a metered amount every 15 minutes. One unit should treat 6000 ft of closed air space… For regular, non-metered applications, spray room until a light fog forms. To sanitize the air, spray 6 to 8 seconds in an average size room (10’x10′).
  • General Toxicity Observations: Upon reviewing the available toxicity information, the Agency has concluded that there are no endpoints of concern for oral, dermal, or inhalation exposure to propylene glycol and dipropylene glycol. This conclusion is based on the results of toxicity testing of propylene glycol and dipropylene glycol in which dose levels near or above testing limits (as established in the OPPTS 870 series harmonized test guidelines) were employed in experimental animal studies and no significant toxicity observed.
  • Carcinogenicity Classification: A review of the available data has shown propylene glycol and dipropylene glycol to be negative for carcinogenicity in studies conducted up to the testing limit doses established by the Agency; therefore, no further carcinogenic analysis is required.
  • FQPA Safety Factor: The FQPA Safety Factor (as required by the Food Quality Protection Act of 1996) is intended to provide an additional 10-fold safety factor (10X), to protect for special sensitivity in infants and children to specific pesticide residues in food, drinking water, or residential exposures, or to compensate for an incomplete database. The FQPA Safety Factor has been removed (i.e., reduced to 1X) for propylene glycol and dipropylene glycol because there is no pre- or post-natal evidence for increased susceptibility following exposure. Further, the Agency has concluded that there are no endpoints of concern for oral, dermal, or inhalation exposure to propylene glycol and dipropylene glycol based on the low toxicity observed in studies conducted near or above testing limit doses as established in the OPPTS 870 series harmonized test guidelines. Therefore, quantitative risk assessment was not conducted for propylene glycol and dipropylene glycol.

2013: Analysis of refill liquids for electronic cigarettes (PDF 9 pages) 

  • Conclusion: The nicotine content of electronic cigarette refill bottles is close to what is stated on the label. Impurities are detectable in several brands above the level set for nicotine products in the European Pharmacopoeia, but below the level where they would be likely to cause harm.

2014: Peering through the mist: systematic review of what the chemistry of contaminants in 

electronic cigarettes tells us about health risks – AbstractPeer Review ReportsStudy 

(PDF 14 pages)

  • Conclusion: Current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces

2017: A Review on the Safety of Inhalation of Propylene Glycol in E-cigarettes (PDF

pages – contains a detailed conclusion) 

  • Introduction: “An electronic cigarette, or e-cigarette, is an electrical device that simulates the act of cigarette smoking by producing an inhaled mist bearing the physical sensation, appearance, and often the flavor and nicotine content of inhaled tobacco smoke. The primary stated use of the e-cigarette is a safe alternative to tobacco smoking, or as a smoking cessation device, while it attempts to deliver the experience of smoking without, or with greatly reduced, adverse health effects. However, the FDA in a July 22, 2009 press conference adopted the position that it will presume that e-cigarettes are as hazardous as conventional cigarettes. An opposing view is held by the Tobacco Control Task Force of the American Association of Public Health Physicians who has indicated that e-cigarettes closely resemble Nicotine Replacement Therapy (NRT) products approved by the FDA. Tests performed by the FDA have shown that e-cigarettes have similar nicotine levels and trace contaminants as NRT products. The Ruyan e-cigarettes use micro-electronics to vaporize, very small quantities of nicotine dissolved in propylene glycol into a fine aerosol with each puff. Nicotine and Propylene Glycol are two small molecules with known safety profiles. Propylene glycol (PG) is generally recognized as safe by oral, dermal or inhalation routes and has been a common ingredient in all American made tobacco cigarettes for seven decades.”

2017: Toxicity of the main electronic cigarette components, propylene glycol, glycerin, and 

nicotine, in Sprague-Dawley rats in a 90-day OECD inhalation study complemented by 

molecular endpoints.  (PDF 18 pages)

  • Conclusion… Standard toxicological endpoints were complemented with systems toxicological analyses using transcriptomics, proteomics, and lipidomics of lung tissue, liver tissue, and serum. Both standard and systems toxicology endpoints demonstrated very limited biological effects of PG/VG aerosol with no signs of toxicity Systems toxicology analyses detected biological effects of nicotine exposure, which included up-regulation of the xenobiotic-metabolizing enzymes Cyp1a1 and Fmo3 in the lung and metabolic effects, likely interlinked with a generalized stress response to nicotine present in the exposure aerosols.” 

2020: Tobacco-Specific Nitrosamines (NNAL, NNN, NAT, and NAB) Exposures in the US Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013–2014) (PDF 11 pages)

  • Among established, every day, exclusive tobacco product users, the geometric mean urinary NNAL concentration was 
    • highest for smokeless tobacco users (993.3 ng/g creatinine), 
    • followed by all types of combustible tobacco product users (285.4 ng/g creatinine), 
    • poly tobacco users (278.6 ng/g creatinine), 
    • and e-cigarette product users (6.3 ng/g creatinine).

Cardiovascular System

ENDS – (Not Ingredient Specific

2010: A clinical laboratory model for evaluating the acute effects of electronic “cigarettes”: nicotine delivery profile and cardiovascular and subjective effects (PDF 15 pages) 

  • Heart rate increased from an average (SD) of 65.7 (10.4) bpm at baseline to a peak of 80.3 (10.9) bpm five minutes after the first administration under the tobacco cigarette condition. No significant changes in heart rate were observed for the e-cigarette or sham conditions.
  • Under these acute testing conditions, neither of the electronic cigarettes exposed users to measurable levels of nicotine or CO, although both suppressed nicotine/tobacco abstinence symptom ratings. 

2012: Acute effects of electronic and tobacco cigarette smoking on complete blood count 

(Abstract only, must pay to view whole study / PDF)

  • Active and passive tobacco cigarette smoking increased white blood cell, lymphocyte, and granulocyte counts for at least one hour in smokers and never smokers. Active and passive tobacco cigarette smoking increase the secondary proteins of acute inflammatory load for at least one hour.
  • It is concluded that acute active and passive smoking using the e-cigarettes tested in the current study does not influence CBC indices in smokers and never smokers. The results demonstrated that CBC indices remained unchanged during the control session and the active and passive e-cigarette smoking sessions.

2013: Chronic Idiopathic Neutrophilia in A Smoker, Relieved after Smoking Cessation with the 

Use of Electronic Cigarette: a Case Report   (PDF 7 pages)

  • A male Caucasian patient, born in 1977, presented in September 2005 with asymptomatic elevation of white blood cell and neutrophil count, and mildly-elevated C-reactive protein levels. He was a smoker since 1996 and was treated with 20 mg/day of simvastatin since 2003 due to hyperlipidemia. Clinical examination, and laboratory and imaging investigations ruled out any infectious, haematological, rheumatological, or endocrine conditions. He was followed-up regularly and was advised to stop smoking. He had 2 unsuccessful attempts to quit smoking; one was unassisted and the second was performed with the use of both varenicline and nicotine replacement therapy (patches). During the subsequent 6.5 years, his leukocyte and C-reactive protein levels were repeatedly elevated; the condition was consistent with chronic idiopathic neutrophilia. In February 2012, he started using electronic cigarettes and he managed to quit smoking within 10 days. After 6 months, laboratory examination showed normalized leukocyte count and C-reactive protein levels, confirmed immediately by a second laboratory and by repeated tests after 1 and 2 months.
  • Smoking cessation with the use of electronic cigarette led to reversal of chronic idiopathic neutrophilia. The daily use of electronic cigarette may help preserve the beneficial effects of smoking cessation.

2016: Cigarette smoke but not electronic cigarette aerosol activates a stress response in human coronary artery endothelial cells in culture (PDF 5 pages)

  • Human coronary artery endothelial cells show a biological response to cigarette smoke.
  • This response was not seen following exposure to e-cigarette aerosol.
  • Using e-cigarettes instead of cigarettes may reduce immediate cardiovascular harms.

2017: Have combustible cigarettes met their match? The nicotine delivery profiles and harmful constituent exposures of second-generation (G2) and third-generation (G3) electronic cigarette users (PDF 6 pages)

  • While not harmless, electronic cigarettes (e-cigarettes) have demonstrated a much more favourable toxicological profile than combustible cigarettes—the worldwide leading cause of preventable death. Average eCO levels (ppm) were significantly higher in smokers than in e-cigarette users. Compared with cigarettes, G2 and G3 e-cigarettes resulted in significantly lower levels of exposure to a potent lung carcinogen and cardiovascular toxicant.

2017: Electronic cigarette smoking increases of arterial stiffness and oxidative stress to a lesser extent than a single normal cigarette: an acute and chronic study (PDF 1 page)

  • Electronic cigarette smoking causes a smaller increase of arterial stiffness and oxidative stress, compared to a single normal cigarette in an acute setting. Replacement of normal cigarettes by a moderate nicotine concentration electronic cigarette results in improved aortic elasticity and oxidative stress within 1 month.

2019: Global Forum on Nicotine (GFN) The effect of electronic nicotine delivery systems (ends) 

and new tobacco products on the risk of cardiovascular disease in people with high 

tobacco dependence 

  • Switching to ENDS/NTPs and nicotine delivery with cigarette smoke’s harmful effects elimination does not interrupt blood oxygen transport function which allows to avoid vessel endothelial damage. The obtained results show significantly less harmful influence of ENDS/NTPs on cardio-vascular function if compared to tobacco smoke and confirm the possibility to consider them as harm reduction products for smokers who do not want or are not ready to quit smoking completely.
  • Poster that goes with the study
  • 2017 Article about this study

2019: Letter that debunks this study: Electronic Cigarette Use and Myocardial Infarction Among 

Adults in the US Population Assessment of Tobacco and Health 

2019:  Is E-Cigarette Use associated with coronary heart disease and myocardial infarction?  

Insights from the 2016 and 2017 National Health Interview Surveys 

  • The pooled analysis of the 2016 and 2017 NHIS showed no association between e-cigarette use and MI or CHD. The associations between established risk factors, including smoking, and both conditions were remarkably consistent. The inconsistent associations observed in single-year surveys and the cross-sectional design of the NHIS cannot substantiate any link between e-cigarette use and an elevated risk for MI or CHD. Longitudinal studies are needed to explore the effects of e-cigarette use on cardiovascular disease.

2019: (November 15) Cardiovascular Effects of Switching From Tobacco Cigarettes to Electronic Cigarettes (Jacob George, MD, Muhammad Hussain, MSc, Thenmalar Vadiveloo, PhD, Sheila Ireland, BSc, Pippa Hopkinson, BSc, Allan D.Struthers, MD, Peter T. Donnan, PhD, Faisel Khan, PhD, Chim C.Lang, MD

  • E-cigarette (EC) use is increasing exponentially worldwide. The early cardiovascular effects of switching from tobacco cigarettes (TC) to EC in chronic smokers is unknown. Meta-analysis of flow-mediated dilation (FMD) studies indicate 13% lower pooled, adjusted relative risks of cardiovascular events with every 1% improvement in FMD.

2019: Electronic cigarettes and cardiovascular health: what do we know so far? (PDF 16 pages)

  • Though they may not be as harmless as previously proposed, it seems likely that on the spectrum of tobacco products, ECs are less harmful than TCs, and there is increasing evidence that ECs may help promote TC cessation. As such, ECs may be helpful for risk reduction

2020: Effects of electronic cigarette on platelet and vascular function after four months of use (Must pay to view PDF version)

  • Electronic Cigarette vaping for four months, has a neutral effect on platelet aggregation of healthy smokers.
  • Continuation of tobacco cigarette smoking further deteriorates platelet function during 4 months of use.
  • Electronic cigarette vaping improves arterial elastic properties and oxidative stress after 4 months of use
  • Tobacco cigarette smoking causes further impairment of arterial elasticity and oxidative stress during 4 months of use

2020: Differential Effects of Tobacco Cigarettes and Electronic Cigarettes on Endothelial Function in Healthy Young People (Must pay to view PDF)

  • Endothelial dysfunction, as measured by flow mediated vasodilation(FMD) is a predictor of future atherosclerosis and adverse cardiovascular events, and is impaired in tobacco cigarette (TC) smokers.
  • FMD was significantly impaired after smoking one TC, but not after vaping an equivalent “dose”(estimated plasma nicotine) of an e-cigarette (EC), consistent with the notion that non-nicotine constituents in TC smoke mediate the impairment.

Flavors (Flavours)

2013: Comparison of the Cytotoxic Potential of Cigarette Smoke and Electronic Cigarette Vapour Extract on Cultured Myocardial Cells (PDF 17 pages)

  • Smoking is an important risk factor for cardiovascular disease and cigarette smoke (CS) has well-established cytotoxic effects on myocardial cells. The purpose of this study was to evaluate the cytotoxic potential of the vapour of 20 EC (e-cigarette)  liquid samples and a “base” liquid sample (50% glycerol and 50% propylene glycol, with no nicotine or flavourings) on cultured myocardial cells. Included were 4 samples produced by using cured tobacco leaves in order to extract the tobacco flavour. Methods: Cytotoxicity was tested according to the ISO 10993-5 standard.
  • In conclusion, from 20 commercially-available EC liquids that were tested in vapour form, four were found to be cytotoxic on cultured cardiomyoblasts. Cytotoxicity was mainly observed in most (but not all) samples produced by using tobacco leaves, while one sample using food-approved flavouring was marginally cytotoxic. EC vapour production by using higher-voltage devices caused a decrease in cell survival. Overall, EC vapour extracts showed significantly higher cell viability compared to CS extract, based on a realistic-use rather than a standardized comparative level of exposure. This supports the concept that ECs may be useful as tobacco harm reduction products

2019 Effects of flavoring compounds used in electronic cigarette refill liquids on endothelial and 

vascular function (PDF 29 pages)

  • Conclusion: Our data indicate that flavorings typically present in e-cig refill liquids do not cause endothelial dysfunction that would result in impaired vasodilation upon acute exposure. In contrast, most of the tested compounds caused endothelium-independent vasorelaxation, albeit at fairly high concentrations that appear to exceed by far the plasma concentrations expected to occur upon vaping flavored liquids.

Nicotine

2016: Cardiovascular toxicity of nicotine: Implications for electronic cigarette use (must pay to view PDF) 

  • Studies of nicotine medications and smokeless tobacco indicate that the risks of nicotine without tobacco combustion products (cigarette smoke) are low compared to cigarette smoking, but are still of concern in people with cardiovascular disease.
  • Electronic cigarettes deliver nicotine without combustion of tobacco and appear to pose low-cardiovascular risk, at least with short-term use, in healthy users.

2017: Sympathomimetic Effects of Acute E‐Cigarette Use: Role of Nicotine and Non‐Nicotine Constituents (PDF 10 pages)

  • The acute sympathomimetic effect of e‐cigarettes is attributable to the inhaled nicotine, not to non‐nicotine constituents in e‐cigarette aerosol
  • Oxidative stress, as estimated by plasma paraoxonase, did not increase following any of the 3 exposures.

Respiratory System 

2014: Effect of Smoking Abstinence and Reduction in Asthmatic Smokers Switching to 

Electronic Cigarettes: Evidence for Harm Reversal    (PDF 13 pages)

  • The e-cig may help smokers with asthma to reduce their cigarette consumption or remain abstinent and hence reduce the burden of smoking-related asthma symptoms. The positive findings observed with e-cigs allows us to advance the hypothesis that these products may be valuable for smoking cessation and/or tobacco harm reduction also in asthma patients who smoke.
  • By substantially reducing number of cigarettes smoked per day and exposure to their hazardous toxicants, e-cigs may not only improve asthma symptoms and pulmonary function but may also confer an overall health advantage in smokers with asthma [13]. Therefore, e-cig use in asthmatic smokers unable or unwilling to quit should be exploited as a safer alternative approach to harm-reversal (i.e., specific reversal of asthma-related outcomes) and, in general, to harm-reduction (i.e., overall reduction of smoke-related diseases).

2016: Evidence for harm reduction in COPD smokers who switch to electronic cigarettes (EC’s)  

(PDF 10 pages)

  • Conclusion: “These findings suggest that ECs use may aid smokers with COPD reduce their cigarette consumption or remain abstinent, which results in marked improvements in annual exacerbation rate as well as subjective and objective COPD outcomes.” 

2016: Changes in the Frequency of Airway Infections in Smokers Who Switched to Vaping: 

Results of an Online Survey   (PDF 3 Pages) 

  • Results: “Altogether 941 responses were received. Overall, 29% of responders reported no change in respiratory symptoms, 5% reported worsening, and 66% reported an improvement (95% CI=62.9-69.0).” 

2016: Changes in breathomics from a 1‐year randomized smoking cessation trial of electronic 

cigarettes  (Must pay to download full text / PDF)

  • Conclusion: “Smokers invited to switch to electronic cigarettes who completely abstained from smoking showed steady progressive improvements in their exhaled breath measurements and symptom scores. FeNo and eCO normalization is highly supportive of improved respiratory health outcomes and adds to the notion that quitting from tobacco smoking can reverse harm in the lung.” 

2016: Respiratory infections and pneumonia: potential benefits of switching from smoking to 

Vaping (PDF 4 pages) 

  • Also, given that the propylene glycol in EC aerosols is a potent bactericidal agent, switching from smoking to regular vaping is likely to produce additional lung health benefits.
  • In conclusion, smokers who quit by switching to regular ECs use can reduce risk and reverse harm from tobacco smoking. 
  • Innovation in the e-vapour category is likely not only to further minimise residual health risks, but also to maximise health benefits.

2017: E-cigarettes in patients with COPD: current perspectives (PDF 8 pages)

  • Conclusion: “Although ECs are not risk free, they are much less harmful than conventional tobacco smoking. The emerging clinical evidence suggests that ECs are unlikely to raise significant health concerns for the respiratory tract under normal conditions of use, even in smokers with preexisting lung disease. In particular, recent studies in COPD and chronic asthma suggest that substitution of conventional tobacco cigarettes for ECs can ameliorate subjective and objective disease-related outcomes and exacerbation rates as well as improving success in abstaining from smoking long term.” 

2017: Reduced biological effect of e-cigarette aerosol compared to cigarette smoke evaluated in 

vitro using normalized nicotine dose and RNA-seq-based toxicogenomics  (PDF 16 pages)

  • Here, we assessed the transcriptional response of a primary 3D airway model acutely exposed to e-cigarette aerosol and cigarette (3R4F) smoke.
  • Based on equivalent or higher nicotine delivery, an acute exposure to e-cigarette aerosol had a reduced impact on gene expression compared to 3R4F smoke exposure in vitro.
  • Therefore, we can conclude that the data strongly supports the adverse effect of acute exposure to cigarette smoke on MucilAir™ cells with functional enrichment for cancer, inflammation and fibrosis genes. In contrast, RNA-seq-based toxicogenomics showed a reduced impact of e-cigarette aerosols acute exposure on MucilAir™ cells compared with 3R4F reference cigarette at equivalent or higher dose of nicotine exposure.

2017: Electronic cigarette vapor alters the lateral structure but not tensiometric properties of calf lung surfactant (PDF 13 pages)

  • While both e-cigarette vapor and conventional cigarette smoke affect surfactant lateral structure, only cigarette smoke disrupts surfactant interfacial properties. The surfactant inhibitory compound in conventional cigarettes is tar, which is a product of burning and is thus absent in e-cigarette vapor.

2018: Health effects in COPD smokers who switch to electronic cigarettes: a 

retrospective-prospective 3-year follow-up   (PDF 10 pages)

  • Conclusion: “The present study suggests that EC use may ameliorate objective and subjective COPD outcomes and that the benefits gained may persist long-term. EC use may reverse some of the harm resulting from tobacco smoking in COPD patients.” 

2019: The effect of e-cigarette aerosol emissions on respiratory health: a narrative review.  

(PDF 18 pages) 

  • Expert opinion: There is growing evidence to support the relative safety of E-Cigarette (EC) emission aerosols for the respiratory tract compared to tobacco smoke. Public Health England estimated, on the basis of a review of 185 studies, that vaping an e-cigarette is likely to be at least 95% less harmful than smoking a regular cigarette. In 2016, the Royal College of Physicians reaffirmed this figure, estimating the risk of long-term inhalation of e-cigarette aerosol to be unlikely to exceed 5% of the risk associated with long-term cigarette smoking. This review article shows that although some potential effects on respiratory cell types can be shown in vitro, and low levels of chronic irritation of the respiratory tract can be anticipated at certain levels of vaping, these effects are much less than those of smoking. The clinical evidence confirms that ECs are unlikely to raise significant health concerns for the respiratory tract under normal conditions of use. Former smokers using and smokers intending to use ECs as a substitute for smoking should receive correct information about residual risks and potential benefits of these products. Promoting further access to ECs may offer an opportunity to reduce or prevent some of the otherwise inevitable burden of respiratory morbidity and mortality caused by tobacco smoking
  • In an Expert Review in Respiratory Medicine article published about 7 years ago [Caponnetto P, Campagna D, Papale G, et al. The emerging phenomenon of electronic cigarettes. Expert Rev Respir Med. 2012 Feb; 6(1):63–74.., we discussed several important research developments and future avenues for e-cigarette science. In the authors’ view, those expert opinions have been substantiated by the growing body of evidence. We therefore reiterate our prediction that EC use is the most effective method of substituting tobacco cigarettes for those smokers who are unable or unwilling to quit and we are now confident that current vaping products are much less harmful than conventional cigarettes as well as earlier EC designs.

2020: Benefits of e-cigarettes in smoking reduction and in pulmonary health among chronic smokers undergoing a lung cancer screening program at 6 months (Must pay to view PDF) 

  • The study is a double-blind randomized controlled trial. Two hundred and ten smokers were randomized into three groups: nicotine e-cigarette (8 mg/mL nicotine concentration), nicotine-free e-cigarettes (placebo), and control with 1:1:1 ratio. All participants received a 3 months cessation program that included a cognitive-behavioral intervention aimed at supporting people in changing their behavior and improving motivation to quit.
  • After 6 months about 20% of the entire sample stopped smoking. Participants who used e-cigarettes with nicotine smoked fewer tobacco cigarettes than any other group after 6 months.
  • Our data add to the efficacy and safety of e-cigarettes in helping smokers reducing tobacco consumption and improving pulmonary health status.
  • Pulmonary health, assessed with self-reported measures, clinical evaluations and the Leicester Cough Questionnaire, improved in participants who stopped smoking compared to their own baseline. Moreover, participants in this group [nicotine e-cigarettes] showed the lowest level of exhaled carbon monoxide, and the lowest level of dependence compared to the nicotine-free e-cigarette and control conditions.

2020: E-Cigarettes and Respiratory Disease: A Replication, Extension, and Future Directions (Must pay to view PDF)

  • The statistical associations between e-cigarette use and respiratory disease are driven by e-cigarette users who are also current or former smokers of combustible tobacco. 
  • A striking feature of the data is that almost all e-cigarette users were either current or former smokers of combustible tobacco.
  • Among respondents who had never smoked combustible tobacco, we find no evidence that current or former e-cigarette use is associated with respiratory disease.

2020: Exclusive e-cigarette users report lower levels of respiratory symptoms relative to dual e-cigarette and cigarette users  (Must pay to view PDF)

  • Findings suggest that differences in respiratory symptoms between dual and exclusive e-cigarette users appear to be attributable to combustible cigarette smoking, rather than more intense or frequent e-cigarette use across groups.

2020: Investigation on the antibacterial activity of electronic cigarette liquids (ECLs): a proof of concept study (online ahead of print, no PDF found)

  • Our results have shown that flavors considerably enhance antibacterial activity.
  • This study provides important evidence that should be taken into consideration in further investigative approaches, to clarify the different sensitivity of the various bacterial species to e-liquids, including the respiratory microbiota, to highlight the possible role of flavors and nicotine. 

2020: COPD smokers who switched to e-cigarettes: health outcomes at 5-year follow up (PDF 15 pages)

  • The present study suggests that EC use may ameliorate objective and subjective COPD outcomes, and that the benefits gained appear to persist long term. EC use for abstinence and smoking reduction may ameliorate some of the harm resulting from tobacco smoking in COPD patients.

Cancer

2016: Patients with lung cancer: Are electronic cigarettes harmful or useful? (must pay to view PDF)

  • Based on current knowledge, for patients with lung or other forms of cancer who would otherwise continue to smoke, e-cigarettes offer an alternative way to quit smoking while they undergo medical treatment. The option to switch to e-cigarettes should be considered by healthcare practitioners with patients with cancer who would otherwise continue to smoke. 

2017: Comparing the cancer potencies of emissions from vapourised nicotine products 

including e-cigarettes with those of tobacco smoke (PDF 8 pages) 

  • “Most e-cigarette analyses indicate cancer potencies <1% that of tobacco smoke and <10% that of a heat-not-burn prototype, although a minority of analyses indicate higher potencies.”
  • Optimal combinations of device settings, liquid formulation and vaping behaviour normally result in e-cigarette emissions with much less carcinogenic potency than tobacco smoke.
  • Article in Lung Disease News: E-Cigarettes Carry Much Less Risk of Lung Cancer Than Cigarette Smoke, Study Finds 

2017: Comparative tumor promotion assessment of e‐cigarette and cigarettes using the in vitro Bhas 42 cell transformation assay (PDF 9 pages)

  • Results from this study suggest that e‐cigarettes may have reduced tumor promoter activity compared to conventional cigarettes and therefore may provide a safer alternative to cigarettes.

2017: Have combustible cigarettes met their match? The nicotine delivery profiles and harmful constituent exposures of second-generation (G2) and third-generation (G3) electronic cigarette users (PDF 6 pages)

  • While not harmless, electronic cigarettes (e-cigarettes) have demonstrated a much more favourable toxicological profile than combustible cigarettes—the worldwide leading cause of preventable death. Average eCO levels (ppm) were significantly higher in smokers than in e-cigarette users. Compared with cigarettes, G2 and G3 e-cigarettes resulted in significantly lower levels of exposure to a potent lung carcinogen and cardiovascular toxicant.

2017: Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine 

Replacement Therapy Users: A Cross-sectional Study (PDF 15 pages)

  • Conclusion: “Former smokers with long-term e-cigarette–only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette–only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.” 

2018: Electronic cigarette use among patients with cancer: Reasons for use, beliefs, and patient-provider communication (PDF 15 pages)

  • Smoking tobacco cigarettes after a cancer diagnosis increases risk for several serious adverse outcomes. Thus, patients can significantly benefit from quitting smoking. Electronic cigarettes are an increasingly popular cessation method.
  • Patients with cancer who use e-cigarettes have positive attitudes toward these devices and use them to aid in smoking cessation. Most participants identified smoking cessation as the reason for initiating (81%) and continuing (60%) e-cigarette use.
  • Patients characterized e-cigarettes as more satisfying, more useful for quitting smoking, and more effective at reducing cancer-related stress than nicotine replacement therapies.

2020: Cancer potencies and margin of exposure used for comparative risk assessment of heated tobacco products (HTPs) and electronic cigarettes (ECs) aerosols with cigarette smoke (PDF 16 pages)

  • Even if they should not be considered as risk-free products, however, HTPs and ECs lead to an appreciable risk reduction in comparison to cigarettes, both for cancer and non-cancer diseases. According to the current knowledge, and more specifically to the data presented here, HTPs and ECs might be considered as an acceptable reduced risk substitute for cigarettes for legal-age smokers who would otherwise continue smoking cigarettes.
  • A more pronounced cancer risk reduction was observed when comparing the mean lifetime cancer risk for the considered ECs with that for cigarette smoke. This reduction was about two orders of magnitude (ratio of 0.009 and 0.014) with 2.42·10–4 and 3.95·10–4 for ECs compared to 2.73·10–2 for cigarettes. In terms of consumers, this would mean that 1 out of 36 cigarette smokers vs. 1 out of 4132 or 1 out of 2531 EC consumers may develop a cancer if the cancer root cause would be only associated with exposure to the considered HPHCs.

Oral Health

2019: A Comparison of Flavorless ElectronicCigarette-Generated Aerosol and Conventional Cigarette Smoke on the Planktonic Growth of Common Oral Commensal Streptococci (PDF 22 pages)

  • A potential implication of these results is that flavorless E-liquids and their generated aerosol induce less tooth decay and periodontal disease than traditional cigarette smoke.
  • A case for improving oral health (and overall health) could be made by federal health regulatory agencies for promoting the use of electronic nicotine delivery systems over the use of traditional cigarettes as a means of harm reduction.

2020: Impact of Electronic Cigarettes on Oral Health: a Review (PDF 8 pages)

  • Several self-reported and randomized studies suggest that e‑cigarettes are a harm-reduction strategy that may improve the oral and general health of smokers and may contribute to smoking cessation.
  • Based on the available literature, it is possible to recommend the use of e‑cigarettes as a temporary alternative for harm reduction and as an aid to smoking cessation. 

Adults Who Smoke

Dual Use 

2017 Differences between Dual Users and Switchers Center around Vaping Behavior and Its 

Experiences Rather than Beliefs and Attitudes (PDF 15 pages) 

  • To the extent that dual users substantially lower the number of cigarettes, they will reduce health risks from smoking. However, from a medical point of view, exclusive vaping is preferable to dual use;
  • Differences between dual users and switchers center around variables proximal to the vaping behavior and its experienced effects rather than hinging on more general vaping-related beliefs and attitudes.
  • After e-cig initiation, dual users decreased tobacco consumption by 82% and were low-to-moderately cigarette dependent.
  • The two groups (dual users and switchers) reported mostly using a flavor other than tobacco.

2019 Perceived relative harm of using e-cigarettes predicts future product switching among US 

adult cigarette and e-cigarette dual users.  (Must pay to view PDF)

  • Compared with those with other perceptions of e‐cigarette harm, dual users who perceived e‐cigarettes as less harmful than cigarettes were more likely to become exclusive e‐cigarette users 1 year later.

2019 Vaping patterns, nicotine dependence and reasons for vaping among American Indian 

dual users of cigarettes and electronic cigarettes.  (PDF 8 pages)

  • …the ten-item Penn State Dependence Index (PSDI) suggested greater dependence on smoking than vaping
  • The most common reasons for vaping were to reduce smoking (79%), enjoyment of flavors (78%), and ability to vape where smoking is not allowed (73%). Perceptions of less harm to others (69%) or to self were the next most common (65%). Fewer than half used ECs to reduce stress, for affordability, or because others used them.

Economic Impact

2018: Behavioral Economic Purchase Tasks to Estimate Demand for Novel Nicotine/tobacco Products and Prospectively Predict Future Use: Evidence From The Netherlands (Must pay to view PDF)

  • Smokers valued FMCs [factory made cigarettes] more than ECs [electronic cigarettes] or VLNCs, [very low nicotine cigarettes] and FMCs were less sensitive to price increases. Demand indices predicted use of commercially available products over a 15 month period. 
  • To serve as viable substitutes for FMCs, ECs and VLNCs will need to be priced lower than FMCs.

2019: Expenditure on smoking and alternative nicotine delivery products: a population survey in 

England   (Must pay to view full text / PDF)

  • Conclusion: “In England, expenditure among e‐cigarette and nicotine replacement therapy users is approximately one‐third of the expenditure of smokers. The average smoker may save an estimated £15.06 per week by switching completely to e‐cigarettes or £13.04 per week by switching to nicotine replacement therapy, although this is likely to differ according to individual usage patterns.” 

2019 The Impact of Electronic Cigarettes on Cigarette Smoking By Americans and Its Health 

and Economic Implications  (PDF 50 pages) 

  • In this study, we examined the growing use of electronic cigarettes and its implications. The wide use of e-cigarettes is a very recent development, and issues regarding their long-term effects and significance cannot be fully analyzed at this time. Using CDC and other data covering the last decade, however, we examined the relationship between the recent sharp increase in e-cigarette use among Americans and the contemporaneous acceleration in the declining rate of cigarette smoking. We found that the sharp increase in e-cigarette use across many groups can explain as much as 70 percent of the accelerating decline in smoking rates. We also found no reasonable evidential basis for concerns that e-cigarettes are a gateway to cigarette smoking. We further found that e-cigarettes are highly effective in helping people stop smoking cigarettes.
  • Finally, we analyzed the impact of the sharp increase in e-cigarette use and the accelerating decline in cigarette smoking on healthcare costs and economic productivity. We found that while e-cigarette users incur lower healthcare costs than cigarette smokers or ex-smokers, the longer lifespans of e-cigarette users and ex-smokers who used e-cigarettes to quit smoking result in higher lifetime healthcare costs. However, we also found that the value of the additional years of life associated with using e-cigarettes instead of smoking is much greater than the additional healthcare costs. Lastly, we found that the increase in e-cigarette use and the associated reduction in smoking rates results in large productivity benefits, mainly from lower rates of illness.

2019: Cost‐effectiveness of e‐cigarettes compared with nicotine replacement therapy in stop 

smoking services in England (TEC study): a randomized controlled trial  (Must pay to view PDF)

  • Using e‐cigarettes as a smoking cessation aid with standard behavioural support in stop‐smoking services in England is likely to be more cost‐effective than using nicotine replacement therapy in the same setting.

Flavors

2013: Impact of Flavour Variability on Electronic Cigarette Use Experience: An Internet Survey 

(PDF 11 pages)

  • 4,618 participants were included in the analysis, with 4,515 reporting current smoking status (current vs. former smokers).
  • More than 90% were former smokers. The mean age was 40 years
  • At the time of participation, most commonly used flavours were fruits, followed by sweets. 
  • Most participants (68.3%) were switching between flavours on a daily basis or within the day, with former smokers switching more frequently. More than half of the study sample mentioned that they like the variety of flavours and that the taste gets blunt from long-term use of the same flavour. The average score for importance of flavours variability in reducing or quitting smoking was 4 (“very important”). Finally, the majority of participants stated that restricting variability of flavours would make the EC experience less enjoyable while almost half of them answered that it would increase craving for tobacco cigarettes and would make reducing or completely substituting smoking less likely.
  • The results of this survey indicate that EC liquid flavourings play a major role in the overall experience of dedicated users and support the hypothesis that they are important contributors in reducing or eliminating smoking consumption. 

2015: The Impact of Flavor Descriptors on Nonsmoking Teens’ and Adult Smokers’ Interest in Electronic Cigarettes (PDF 8 pages) 

  • Nonsmoking teens’ interest in e-cigarettes was very low. Adult smokers’ interest was significantly higher overall and for each flavor. 
  • Teen interest did not vary by flavor, but adult interest did.
  • Past-30-day adult e-cigarette users had the greatest interest in e-cigarettes, and their interest was most affected by flavor. 
  • Nonsmoking teens who had never tried e-cigarettes had the lowest interest, followed by adults who had never tried e-cigarettes

2015: Preferred Flavors and Reasons for E-cigarette Use and Discontinued Use Among Never, Current, and Former Smokers (PDF 21 pages)

  • Never users had significantly lower prevalence of use of alcohol, marijuana, and other tobacco products (take less risks)
  • Among current e-cigarette users, the most commonly used flavor was fruit flavors (67%)
  • The most commonly reported reasons for e-cigarette use were “they might be less harmful than cigarettes” (77%); “they don’t smell” (77%); “they help people quit smoking” (66%); and “they cost less than other forms of tobacco” (62%); these reasons were more frequently endorsed by former smokers.
  • Over 90% of former cigarette smokers who were current e-cigarette users reported using e-cigarettes to quit smoking.
  • Over half of never smokers who are former e-cigarette users said they did not recently use e-cigarettes because they “just don’t think about it”, possibly indicating that addiction did not play a role in their use.

2016: Cigarette smoking and electronic cigarette vaping patterns as a function of e-cigarette flavourings PDF 6 pages)

  • The findings suggest that adoption of e-cigarettes in smokers may influence smoking rates of people who smoke.
  • E-cigarette vaping rates are influenced by flavourings.
  • These findings may have implications for the utility of e-cigarettes as a nicotine replacement device and for the regulation of flavourings in e-cigarettes for harm reduction.

2018 Patterns of flavored e-cigarette use among adults vapers in the United States: an internet 

survey. 

  • In conclusion, this cross-sectional study of a very large sample of adult US e-cigarette users, most of which were former smokers, identified the importance of non-tobacco flavors in e-cigarette use initiation and sustained use, and their contribution to smoking cessation and relapse prevention. This information should be considered by regulators in order to avoid unintentional adverse effects of over-restrictive regulation on e-cigarette flavors.

2018: Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult 

frequent e-cigarette users in the USA (PDF 14 pages)

  • Conclusion: Adult frequent e-cigarette users in the USA who have completely switched from smoking cigarettes to using e-cigarettes are increasingly likely to have initiated e-cigarette use with non-tobacco flavors and to have transitioned from tobacco to non-tobacco flavors over time. Restricting access to non-tobacco e-cigarette flavors may discourage smokers from attempting to switch to e-cigarettes.

2018: Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment (PDF 8 pages)

  • A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine

2019:  Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users  (PDF 9 pages)

  • Using a nontobacco flavor they liked made former smokers less likely to return to cigarette smoking.
  • Our results regarding anticipated reactions to FDA e-cigarette flavor regulation suggest complexities such that the benefits and risks of flavor ban need to be carefully evaluated.
  • However, a majority anticipated that they would personally attempt to circumvent potential FDA regulations of e-cigarettes by obtaining e-cigarette flavors from various illicit sources (e.g., Internet orders from foreign countries) or even self-making flavors.
  • The use of flavoring agents purchased from unregulated sources could lead to additional unanticipated toxicities.
  • It is also concerning that some established e-cigarette users believed that they would return to cigarette smoking if nontobacco e-cigarette flavors were banned. Thus, for adult e-cigarette users who use certain flavors to facilitate smoking cessation or reduction, banning all nontobacco flavors could precipitate relapse to smoking.

2019: The role of flavors in vaping initiation and satisfaction among U.S. adults (PDF 6 pages)

  • In terms of cigarette smoking status, 35.6% of respondents were past smokers, and 38.0% were current smokers. 
  • Most common reasons for vaping initiation were as an alternative to cigarettes (43.7%) and because respondents viewed e-cigarettes as less harmful than other tobacco products (31.2%). Flavor was the third most commonly reported reason.
  • Satisfaction among those who bought flavored e-liquid was higher than those who did not buy flavored e-liquid.

2020: Intended and Unintended Effects of Banning Menthol Cigarettes (PDF 66 pages)

  • Menthol bans significantly increased non-menthol cigarette smoking among youths, resulting in no overall net change in youth smoking rates.
  • Menthol bans shifted smokers’ cigarette purchases away from grocery stores and gas stations to First Nations reserves (where the menthol bans do not bind).

2020: Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation (PDF 12 pages)

  • Relative to vaping tobacco flavors, vaping nontobacco-flavored e-cigarettes was not associated with increased youth smoking initiation but was associated with an increase in the odds of adult smoking cessation.

2020: Association of vaping‐related lung injuries with rates of e‐cigarette and cannabis use across US states (Links to PDF – 7 pages)

  • At the same time, policymakers should proceed with caution when considering bans on flavored e‐liquids: restricting legal sales may push some vapers towards illicit sources, user‐modified e‐liquids (e.g. to add flavoring) or even conventional cigarette use. Given EVALI’s potential lethality and a myriad of work suggesting that conventional cigarette use is probably far more dangerous than vaping nicotine, these outcomes could be disastrous for public health.

2020: Reported patterns of vaping to support long-term abstinence from smoking: a cross-sectional survey of a convenience sample of vapers (PDF 9 pages)

  • Most attempts at smoking cessation result in relapse, and smokers generally make multiple quit attempts before succeeding. 
  • Qualitative research suggests e-cigarettes can meet many of the needs of ex-smokers by substituting physical, psychological, social, cultural and identity-related aspects of tobacco addiction. 
  • According to a time-series analysis of data from the Smoking Toolkit study, in which repeated cross-sectional surveys are conducted with a representative sample of households in England, increasing prevalence of e-cigarette use in current smokers was predictive of higher success rates of quit attempts.
  • Most participants were self-reported long-term abstinent smokers (86.3%).
  • Those who start on a low self-reported nicotine e-liquid concentration (strength) will be more likely to relapse to tobacco smoking than those starting on a higher nicotine e-liquid, after controlling for cigarettes per day (CPD) before cessation.
  • Results suggest a change in flavor choices over the course of vaping initiation and uptake. There was a reduction in the proportion of people using a tobacco flavor, and increase in the proportion using a fruit/sweet/food flavor, from initial to current flavor choice 
  • According to the 2017 ASH-A survey, among current users, fruit flavors were the most popular.

2020: The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults (PDF 8 pages)

  • A sample of San Francisco residents aged 18–34 who previously used tobacco products were surveyed about their tobacco use both before and after the ban. 
  • Among the 18–24 age group, there was a significant increase in cigarette smoking.
  • Cigarette smoking increased among 25–34 years old.
  • Banning flavors in e-cigarettes would prompt e-cigarette use cessation but may also push some e-cigarette users to turn to cigarette smoking and could prompt some youth to initiate into smoking instead of e-cigarette use.
  • The proportions of e-cigarettes, cigarettes, and cigars obtained over the internet increased after the ban, and the proportions obtained from retailers outside of San Francisco also increased overall.

Nicotine Levels

2013: Evaluating Nicotine Levels Selection and Patterns of Electronic Cigarette use in a Group of  “Vapers” Who Had Achieved Complete Substitution of Smoking  (PDF 8 pages)

  • Nicotine levels appear to play an important role in achieving and maintaining smoking cessation in the group of motivated subjects studied. High nicotine-containing liquids were used while few mild and temporary side effects were reported. Proposals about regulation should consider the pragmatic use patterns of ECs, especially in consumers who have completely substituted smoking.
  • 42% of participants reported quitting smoking during the first month of EC use.
  • Liquids with nicotine concentration >15 mg/mL were used by 74% of users at initiation of EC use, while 16.2% had to increase the initial nicotine levels in order to achieve complete smoking abstinence.
  • 64.9% reported that from the time of smoking cessation to the time of the interview (8 months median duration of EC use) they reduced the nicotine concentration they were consuming.
  • The vast majority of participants reported better exercise capacity and improved olfactory and gustatory senses.
  • Perceived EC dependency was significantly lower compared to smoking.

2013: Nicotine levels in electronic cigarettes. (PDF 9 pages) 

  • Conclusion: “E-cigarettes (ECs) generate vapor that contains nicotine, but EC brands and models differ in their efficacy and consistency of nicotine vaporization. In ECs, which vaporize nicotine effectively, the amount inhaled from 15 puffs is lower compared with smoking a conventional cigarette.”

2016: Protocol proposal for, and evaluation of, consistency in nicotine delivery from the liquid to the aerosol of electronic cigarettes atomizers: regulatory implications (Must pay to view PDF)

  • Electronic cigarettes that use tank‐type atomizers appear to deliver nicotine in more consistent quantities (within the acceptable limits for medicinal nebulizers and similar to the nicotine inhaler) than electronic cigarettes that use cartomizers. 
  • The protocol for testing nicotine delivery consistency described in this paper could be used effectively for regulatory purposes.

2020: Might limiting liquid nicotine concentration result in more toxic electronic cigarette aerosols? (Must pay to view PDF) 

  • Thus, if users seek a given nicotine yield, regulatory limits on nicotine concentration may have the unintended consequence of increasing exposure to aerosol and respiratory toxicants. This outcome demonstrates that attempting to control ECIG nicotine yield by regulating one factor at a time may have unintended health effects and highlights the need to consider multiple factors and outcomes simultaneously when designing regulations.

2020: Reported patterns of vaping to support long-term abstinence from smoking: a cross-sectional survey of a convenience sample of vapers (PDF 9 pages)

  • Most attempts at smoking cessation result in relapse, and smokers generally make multiple quit attempts before succeeding. 
  • Qualitative research suggests e-cigarettes can meet many of the needs of ex-smokers by substituting physical, psychological, social, cultural and identity-related aspects of tobacco addiction. 
  • According to a time-series analysis of data from the Smoking Toolkit study, in which repeated cross-sectional surveys are conducted with a representative sample of households in England, increasing prevalence of e-cigarette use in current smokers was predictive of higher success rates of quit attempts.
  • Most participants were self-reported long-term abstinent smokers (86.3%).
  • Those who start on a low self-reported nicotine e-liquid concentration (strength) will be more likely to relapse to tobacco smoking than those starting on a higher nicotine e-liquid, after controlling for cigarettes per day (CPD) before cessation.
  • Results suggest a change in flavor choices over the course of vaping initiation and uptake. There was a reduction in the proportion of people using a tobacco flavor, and increase in the proportion using a fruit/sweet/food flavor, from initial to current flavor choice 
  • According to the 2017 ASH-A survey, among current users, fruit flavors were the most popular.

Quitting Smoking: E-cigarette vs. NRT OR E-cigarette with NRT

2011: Successful smoking cessation with electronic cigarettes in smokers with a documented 

history of recurring relapses: a case series  (PDF 6 pages) 

  • The most important message from this case series is that these smokers, with a documented history of recurring relapses, were able to quit smoking and to remain abstinent for at least six months after taking up an electronic cigarette.

2013: Electronic cigarettes for smoking cessation: a randomised controlled trial. 

  • 657 people were randomised (289 to nicotine e-cigarettes, 295 to patches, and 73 to placebo e-cigarettes) and were included in the intention-to-treat analysis. 
  • At 6 months, verified abstinence was 7·3% (21 of 289) with nicotine e-cigarettes, 5·8% (17 of 295) with patches, and 4·1% (three of 73) with placebo e-cigarettes 

2013: A fresh look at tobacco harm reduction: the case for the electronic cigarette  

(PDF 11 pages)

  • Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation.
  •  E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking’s damaging effect, they also replace some of the rituals associated with smoking behaviour.
  • Nicotine’s beneficial effects include correcting problems with concentration, attention and memory, as well as improving symptoms of mood impairments. Keeping such disabilities at bay right now can be a much stronger motivation to continue using nicotine than any threats of diseases that may strike years and years in the future.
  • Nicotine’s beneficial effects can be controlled, and the detrimental effects of the smoky delivery system can be attenuated, by providing the drug via less hazardous delivery systems. Although more research is needed, e-cigs appear to be effective cigarette substitutes for inveterate smokers, and the health improvements enjoyed by switchers do not differ from those enjoyed by tobacco/nicotine abstainers.

2013: Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A 

literature review 

  • When compared to the harmful effects of smoking, these studies suggest that vaping could be used as a possible “harm reduction” tool. There is evidence supporting e-cigarettes as an aide for smoking cessation, at least as successful as currently available FDA-approved NRTs.

2014: Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a 

cross-sectional population study  (PDF 10 pages)

  • Conclusion: “Among smokers who have attempted to stop without professional support, those who use e-cigarettes are more likely to report continued abstinence than those who used a licensed NRT product bought over-the-counter or no aid to cessation. This difference persists after adjusting for a range of smoker characteristics such as nicotine dependence.”

2014: E-cigarette versus nicotine inhaler: comparing the perceptions and experiences of inhaled 

nicotine devices.  Related Article: E-Cigarettes vs. Nicotine Inhalers 

  • “In conclusion, during this brief trial, the e-cigarette was found to be more acceptable, provided more satisfaction and rewards, and had higher perceived benefit than the nicotine inhaler. These findings may explain why the e-cigarette has become popular among smokers while the inhaler has not achieved the same favorability. Based on this difference, e-cigarettes could have the potential to become “tobacco cigarette substitutes,” owing to their high acceptance and perceived effectiveness. While toxicants have been identified in e-cigarettes, they are present at orders of magnitude lower than tobacco cigarettes. As such, e-cigarettes may hold value as a harm reduction strategy among those unwilling or unable to quit. However, given the large variation in the market with respect to brands, more data are needed to demonstrate their efficacy and safety, and to allow physicians to more appropriately inform their patients about these products.” From: (PDF 7 pages)

2016: E-cigarettes: a developing public health consensus 

 From: Public Health England, Action on Smoking and Health, Association of Directors of Public Health, British Lung Foundation, Cancer Research UK, Faculty of Public Health, Fresh North East, Healthier Futures, Public Health Action, Royal College of Physicians, Royal Society for Public Health, UK Centre for Tobacco and Alcohol Studies, UK Health Forum

  • We all agree that e-cigarettes are significantly less harmful than smoking. One in two lifelong smokers dies from their addiction. All the evidence suggests that the health risks posed by e-cigarettes are relatively small by comparison but we must continue to study the long-term effects.
  • And yet, millions of smokers have the impression that e-cigarettes are at least as harmful as tobacco
  • The public health opportunity is in helping smokers to quit, so we may encourage smokers to try vaping but we certainly encourage vapers to stop smoking tobacco completely.
  • We know that e-cigarettes are the most popular quitting tool in the country with more than 10 times as many people using them than using local stop smoking services
  • The current national evidence is that in the UK regular e-cigarette among youth use is almost exclusively confined to those young people who have already smoked, and youth smoking prevalence is continuing to fall
  • We should not forget what is important here. We know that smoking is the number one killer in England and we have a public health responsibility to provide smokers with the information and the tools to help them quit smoking completely and forever.

2018: American Cancer Society Position Statement on Electronic Cigarettes 

  • Based on currently available evidence, using current generation e-cigarettes is less harmful than smoking cigarettes, but the health effects of long-term use are not known. 
  • The ACS has always supported any smoker who is considering quitting, no matter what approach they use; there is nothing more important that they can do for their health.
  • Some smokers, despite firm clinician advice, will not attempt to quit smoking cigarettes and will not use FDA approved cessation medications.  These individuals should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.

2018: Discussions between health professionals and smokers about nicotine vaping products: results from the 2016 ITC Four Country Smoking and Vaping Survey (PDF 15 pages)

  • Despite the need for more evidence on their efficacy and long‐term safety, NVPs are now a more popular method for cessation than licensed NRT and prescription stop‐smoking medications in many countries.
  • In light of this, HPs should be prepared to provide balanced information about NVPs, particularly to smokers who are unable to stop smoking with approved cessation therapies, and for those who are requesting guidance regarding NVPs as a smoking cessation aid
  • Overall, the results from this study have shown that discussions between smokers and HPs about both quitting smoking, and the possible role NVPs could play as a cessation aid, were infrequent in the four countries in 2016. This may represent a lost opportunity for encouraging quitting smoking by providing a potentially attractive option to help smokers to quit.

2019: E-cigarettes compared with nicotine replacement therapy within the UK Stop Smoking Services: the TEC RCT (PDF 108 pages)

  • The primary outcome was CO-validated sustained abstinence rates at 52 weeks. Participants lost to follow-up or not providing biochemical validation were included as non-abstainers. 
  • The 1-year quit rate was 9.9% in the NRT arm and 18.0% in the e-cigarette arm.
  • The e-cigarette arm had significantly higher validated quit rates at all time points. Participants in the e-cigarette arm showed significantly better adherence and experienced fewer urges to smoke throughout the initial 4 weeks of their quit attempt than those in the NRT arm, and gave their allocated product more favourable ratings. They were also more likely to be still using their allocated product at 1 year 
  • Participants assigned to e-cigarettes reported significantly less coughing and phlegm at 1 year than those assigned to NRT
  • A detailed economic analysis confirmed that, because e-cigarettes incur lower NHS costs than NRT and generate a higher quit rate, e-cigarette use is more cost-effective.

2019: Cost‐effectiveness of e‐cigarettes compared with nicotine replacement therapy in stop 

smoking services in England (TEC study): a randomized controlled trial  (Must pay to view PDF)

  • Using e‐cigarettes as a smoking cessation aid with standard behavioural support in stop‐smoking services in England is likely to be more cost‐effective than using nicotine replacement therapy in the same setting.

2019: Effect of Electronic Cigarettes on Smoking Reduction and Cessation in Korean Male 

Smokers: A Randomized Controlled Study   (PDF 8 Pages)

  •  In our study, the effect of e-cigarettes on smoking cessation was similar compared with that of nicotine gum, a well-documented NRT. In addition, e-cigarettes were well tolerated by the study population. Therefore, the use of e-cigarettes as an NRT may be considered for smoking-cessation purposes.

2019: A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy (PDF 9 pages) 

  • Results: A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath.
  • Conclusion: E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.

2019: Nicotine patches used in combination with e-cigarettes (with and without nicotine) for 

smoking cessation: a pragmatic, randomised trial  (PDF 12 pages)

  • In summary, when looking at continuous abstinence from smoking, provision of patches plus a nicotine e-cigarette resulted in three to seven more smokers per 100 quitting long-term (depending on the analyses done) than with patches plus a nicotine-free e-cigarette. The smaller than anticipated sample size meant the study was not sensitive enough to pick up a definitive finding for the second comparison, although analyses suggest combination nicotine therapy—ie, use of a slow release nicotine patch, together with a faster-acting oral nicotine product (in this case a nicotine e-cigarette)—could result in five to ten more smokers per 100 quitting long-term than with monotherapy (ie, nicotine patches alone). Our findings are consistent with the current findings of the Cochrane review of e-cigarettes for smoking cessation and contribute to the growing body of evidence from randomised trials on the efficacy, effectiveness and safety of e-cigarettes for smoking cessation.

2020: QuitNic: A pilot randomised controlled trial comparing nicotine vaping products with nicotine replacement therapy for smoking cessation following residential detoxification (No link to PDF found)

  • This pilot study showed that smoking cessation support involving options for nicotine replacement and Quitline-delivered cognitive behavioural counselling is attractive to people after they have been discharged from SUD (Substance Use Disorder) treatment.
  • Retention was 63% at 6-weeks and 50% at 12-weeks. At 12-weeks, 68% of the NRT group reported using combination NRT while 96% of the NVP group used the device. Acceptability ratings for the products were high in both groups. At 12-weeks, 14% of the NVP group and 18% of the NRT group reported not smoking at all in the last 7 days. Mean CPD (Cigarettes Per Day) among continued smokers decreased significantly between baseline to 12-weeks in both groups; from 19.91 to 4.72 for the NVP group (p<0.001) and from 20.88 to 5.52 in the NRT group (p<0.001). Cravings and withdrawal symptoms significantly decreased for both groups. 

2020: Effectiveness of Electronic Cigarettes in Smoking Cessation: a Systematic Review and Meta-Analysis (PDF 30 pages)

  • Our results suggest that nicotine-ECs may be more effective in smoking cessation when compared to placebo ECs or NRT.

 Quitting Smoking / Preventing Relapse (No comparison to other methods)

2010: Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and 

withdrawal, user preferences and nicotine delivery: randomised cross-over trial   (Must 

pay to download full text / PDF)

  • Conclusions “The 16 mg Ruyan V8 ENDD alleviated desire to smoke after overnight abstinence, was well tolerated and had a pharmacokinetic profile more like the Nicorette inhalator than a tobacco cigarette. Evaluation of the ENDD for longer-term safety, potential for long-term use and efficacy as a cessation aid is needed.”

2010: Electronic cigarettes: a survey of users  (PDF 7 pages)

  • Our results suggest that ecigarettes are used mainly to quit smoking, and may be useful for this purpose.

2011: Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and 

cessation: a prospective 6-month pilot study.   (PDF 12 pages)

  • Sustained 50% reduction in the number of cig/day at week-24 was shown in 13/40(32.5%) participants; their median of 25 cigs/day decreasing to 6 cigs/day (p < 0.001). Sustained 80% reduction was shown in 5/40(12.5%) participants; their median of 30 cigs/day decreasing to 3 cigs/day (p = 0.043). Sustained smoking abstinence at week-24 was observed in 9/40(22.5%) participants, with 6/9 still using the e-Cigarette by the end of the study. Combined sustained 50% reduction and smoking abstinence was shown in 22/40 (55%) participants, with an overall 88% fall in cigs/day.
  • The use of e-Cigarette substantially decreased cigarette consumption without causing significant side effects in smokers not intending to quit 

2011: Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy (must pay 

to view full study or the PDF)

  •  Almost all (97%) used e‐cigarettes containing nicotine.
  • Most (96%) said the e‐cigarette helped them to quit smoking or reduce their smoking (92%). 
  • Reasons for using the e‐cigarette included the perception that it was less toxic than tobacco (84%), to deal with craving for tobacco (79%) and withdrawal symptoms (67%), to quit smoking or avoid relapsing (77%), because it was cheaper than smoking (57%) and to deal with situations where smoking was prohibited (39%). 
  • Most ex‐smokers (79%) feared they might relapse to smoking if they stopped using the e‐cigarette. 
  • Users of nicotine‐containing e‐cigarettes reported better relief of withdrawal and a greater effect on smoking cessation than those using non‐nicotine e‐cigarettes.

2011: Electronic cigarettes (e‐cigs): views of aficionados and clinical/public health 

Perspectives  (PDF 6 pages)

  • The health risks from smoking are large and are known with certainty. Comparatively, the health risks from e‐cig use are likely much smaller (if any) and temporarily switching to e‐cigs will likely yield a large health benefit. 
  • If the patient perceives that the e‐cig is helping them to stay off cigarettes and is not reporting any health problems likely attributable to the e‐cig, then the focus should be on staying smoke‐free rather than e‐cig free. 

2011: Electronic Cigarettes As a Smoking-Cessation Tool: Results from an Online 

Survey (Must pay to view PDF)

  • A large percentage of respondents reported a reduction in the number of cigarettes they smoked (66.8%) and almost half reported abstinence from smoking for a period of time (48.8%). Those respondents using e-cigarettes more than 20 times per day had a quit rate of 70.0%. Of respondents who were not smoking at 6 months, 34.3% were not using e-cigarettes or any nicotine-containing products at the time.

2011: Interviews With “Vapers”: Implications for Future Research With Electronic Cigarettes  

(PDF 8 pages)

  • Experienced users report health gains typical for smoking cessation despite continued vaping.
  • There were pervasive themes including the language and culture of vaping; social and informational support among vapers, motives and perceived benefits of using e-cigs versus cigarettes including cigarette-like enjoyment, cost, restored sense of taste and smell, and improved breathing and exercise tolerance; rapidly reduced nicotine tolerance and dependence; and a strong interest in e-cig–related research and policy.

2012: The electronic-cigarette: Effects on desire to smoke, withdrawal symptoms and cognition 

(must pay to view PDF)

  • The e-cigarette can reduce desire to smoke and nicotine withdrawal symptoms 20 minutes after use.
  •  The nicotine content in this respect may be more important for males.
  • The first study to demonstrate that the nicotine e-cigarette can improve working memory.

2013: E-Cigarettes: Prevalence and Attitudes in Great Britain  (PDF 8 pages)

  • While we found evidence supporting the view that e-cigarette use may be a bridge to quitting, we found very little evidence of e-cigarette use among adults who had never smoked. British smokers would benefit from information about the effective use, risks, and benefits of e-cigarettes, as this might enable the use of e-cigarettes to improve public health.

2013: EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as Tobacco Cigarettes 

Substitute: A Prospective 12-Month Randomized Control Design Study   (PDF 12 pages)

  • Conclusion: “In smokers not intending to quit, the use of e-cigarettes, with or without nicotine, decreased cigarette consumption and elicited enduring tobacco abstinence without causing significant side effects.” 

2013: ‘Vaping’ profiles and preferences: an online survey of electronic cigarette users. (Must pay 

for full text / PDF)

  • “FINDINGS: Seventy-four percent of participants reported not smoking for at least a few weeks since using the e-cigarette and 70% reported reduced urge to smoke. Seventy-two percent of participants used a ‘tank’ system, most commonly, the eGo-C (23%). Mean duration of use was 10 months. Only 1% reported exclusive use of non-nicotine (0 mg) containing liquid. E-cigarettes were generally considered to be satisfying to use; elicit few side effects; be healthier than smoking; improve cough/breathing; and be associated with low levels of craving. Among ex-smokers, ‘time to first vape’ was significantly longer than ‘time to first cigarette’ (t1104  = 11.16, P < 0.001) suggesting a lower level of dependence to e-cigarettes. Ex-smokers reported significantly greater reduction in craving than current smokers (χ(2) 1  = 133.66, P < 0.0007) although few other differences emerged between these groups. Compared with males, females opted more for chocolate/sweet flavours (χ(2) 1  = 16.16, P < 0.001) and liked the e-cigarette because it resembles a cigarette (χ(2) 3  = 42.65, P < 0.001).
  • CONCLUSIONS: E-cigarettes are used primarily for smoking cessation, but for a longer duration than nicotine replacement therapy, and users believe them to be safer than smoking.”

2014: Effectiveness of the Electronic Cigarette: An Eight-Week Flemish Study with Six-Month 

Follow-up on Smoking Reduction, Craving and Experienced Benefits and Complaints 

(PDF 29 pages) 

  • When people, ready to switch to an e-cig, are severely restricted in terms of accessibility of nicotine-containing e-liquids, the success of e-cigs may be endangered. For the e-cig to be and remain successful, it is important that people have easy access to nicotine containing e-liquids.
  • Conclusion: “In a series of controlled lab sessions with e-cig-naïve tobacco smokers, second-generation e-cigs were shown to be immediately and highly effective in reducing abstinence-induced cigarette craving and withdrawal symptoms, while not resulting in increases in eCO. Ad libitum use of e-cigs—in between and until six months after the lab sessions—resulted in remarkable reductions in or (biologically confirmed) complete abstinence from tobacco smoking in almost half of the participants who had no intention to quit smoking. [highlighting added] Eight months after the start of the study 21% of all participants were completely abstinent from tobacco cigarettes. Similar reduction/cessation rates were obtained with guided versus non-guided switching to e-cigs. Part of the observed efficacy of e-cigs in this study may be related to the fact that they allowed to maintain relatively high blood nicotine levels and showed an excellent experienced benefits/complaints ratio, especially in comparison with continued tobacco smoking”…
  • E-cigarette is an attractive long-term alternative and safer source of nicotine to conventional cigarette. Since their invention in 2003, there has been constant innovation and development of more efficient and appealing products. Here we show for the first time that second generation PVs can substantially decrease cigarette consumption without causing significant side effects in smokers not intending to quit. Moreover, overall participants’ perception and acceptance of these products was very good, in particular for those who quit or reduced smoking. Compared to our earlier work with first generation “cig-alikes”, technical problems and difficulties in use familiarization with second generation PVs were negligible. Improved products reliability and attractiveness might have contributed to the very low number of study failures and lost to follow-up and high success rates thus confirming the notion that these products are attractive substitutes for conventional cigarettes. Although large and carefully conducted RCTs will be required to confirm these preliminary encouraging observations, the notion that second generation PVs can substantially decrease cigarette consumption in smokers not intending to quit should be taken into consideration by regulatory authorities seeking to adopt proportional measures for the vapour category 

2014: Success rates with nicotine personal vaporizers: a prospective 6-month pilot study of 

smokers not intending to quit   (PDF 9 pages) 

  • Complete tobacco cessation is the best outcome for smokers, but the powerful addictive qualities of nicotine and of the ritualistic behavior of smoking create a huge hurdle, even for those with a strong desire to quit. Tobacco harm reduction (THR), the substitution of low-risk nicotine products for cigarette smoking, is a realistic strategy for smokers who have difficulty quitting. E-cigarettes are the newest and most promising products for THR. This approach has been recently exploited to reduce or reverse the burden of harm in smokers with mental health disorders and chronic airway disease.

2014: Characteristics, Perceived Side Effects and Benefits of Electronic Cigarette Use: A 

Worldwide Survey of More than 19,000 Consumers  (PDF 18 pages)

  •  The main results of this survey indicate that ECs may be an effective substitute for smoking even in highly dependent subjects who are heavy smokers. Significant benefits are experienced by these people in physiologic functions and in some disease conditions, with former smokers (those who completely substituted smoking with EC use) being more likely to report such beneficial effects.
  • Both former and current smokers initiated EC use with high nicotine-containing liquids. More than one-fifth of the population initiated use with more than 20 mg/mL nicotine concentration, with higher prevalence in former smokers, supporting the hypothesis that nicotine plays an important role in the success of ECs as smoking substitutes [4,16]. This can be attributed to the lower nicotine absorption from EC use compared to smoking [13,17,18]. Such repeated observations should be taken into consideration by the regulatory authorities.
  • The most important reasons for participants to initiate ECs were to reduce or completely quit smoking and to reduce exposure of family members to second-hand smoking. It seems that these subjects are well-informed about the adverse health effects of smoking and are willing to try an alternative product which they consider less harmful.
  • In conclusion, in this large sample of dedicated EC users, it seems that ECs are used as long-term substitutes to smoking. They can be effective even in subjects who are highly dependent on smoking and are heavy smokers. Mild temporary side-effects and significant benefits are reported by this population. Motivation for using ECs comes from their expected less harmful potential compared to smoking.

2014: Reasons for quitting cigarette smoking and electronic cigarette use for cessation help (PDF 14 pages)

  • Thus, this may be the first study to suggest that smokers who want to quit smoking for immediate, extrinsic rewards may be attracted to use e-cigarettes to stop smoking cigarettes than smokers who want to quit smoking for intrinsic reasons such as health concerns. In conclusion, e-cigarettes appear to provide a “smoking” alternative to a section of cigarette smokers who may not quit smoking for health reasons. Public health efforts may need to consider employing e-cigarettes to promote tobacco-related harm reduction.

2014: Cigarette Users’ Interest in Using or Switching to Electronic Nicotine Delivery Systems (ENDS) for Smokeless Tobacco for Harm Reduction, Cessation, or Novelty: A Cross-Sectional Survey of US Adults (PDF 11 pages)

  • This study highlights higher interest in ENDS versus smokeless tobacco and greater interest in both for harm reduction and cessation than due to novelty or smoking restrictions. 
  • 27.2% of current smokers had talked with a health care provider about ENDS, with 18.0% reporting that their provider endorsed ENDS use for cessation. 
  • Developing educational campaigns and informing practitioners about ENDS as cessation or harm reduction aids is critical.

2015: E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and 

Meta-Analysis   (PDF 16 pages) 

  • Conclusions: “This systematic review and meta-analyses assessed the findings of six studies which reported smoking cessation after using e-cigarettes. We found an association between nicotine-enriched e-cigarette use and smoking cessation, suggesting that the devices may be an effective alternative smoking cessation method. We also found that use of e-cigarettes was also associated with a reduction in the number of cigarettes used, suggesting they may also have a role in tobacco harm reduction programs. To our knowledge, this is the most comprehensive evidence to date on this issue, and while there are a number of important implications for further research, these findings provide timely information to inform regulatory strategies.”

2015: A Longitudinal Study of Electronic Cigarette Use Among a Population-Based Sample of 

Adult Smokers: Association With Smoking Cessation and Motivation to Quit    (PDF

Pages) 

  • Results: At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up.
  • Conclusion: Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.

2015: Associations Between E-Cigarette Type, Frequency of Use, and Quitting Smoking: 

Findings From a Longitudinal Online Panel Survey in Great Britain   (PDF 8 pages) 

  • Conclusion: Whether e-cigarette use is associated with quitting depends on type and frequency of use. Compared with respondents not using e-cigarettes, daily tank users were more likely, and non-daily cigalike users were less likely, to have quit. Tanks were more likely to be used by older respondents and respondents with lower education. 

2015: Electronic Cigarettes Efficacy and Safety at 12 Months: Cohort Study (PDF 14 pages) 

  • Results: Follow-up data were available for 236 e-smokers, 491 tobacco smokers, and 232 dual smokers (overall response rate 70.8%). All e-smokers were tobacco ex-smokers. At 12 months, 61.9% of the e-smokers were still abstinent from tobacco smoking; 20.6% of the tobacco smokers and 22.0% of the dual smokers achieved tobacco abstinence. Adjusting for potential confounders, tobacco smoking abstinence or cessation remained significantly more likely among e-smokers…

2016: Patterns of Electronic Cigarette Use Among Adults in the United States   (PDF 5 pages) 

  • Results: Current e-cigarette use is extremely low among never cigarette smokers (0.4%) and former smokers who quit cigarettes 4 or more years ago (0.8%). Although e-cigarette experimentation is most common among current cigarette smokers and young adults, daily use is highest among former smokers who quit in the past year (13.0%) and older adults. Compared to daily cigarette smokers, recently quit smokers were more than four times as likely to be daily users of e-cigarettes ( AOR : 4.33 [95% CI: 3.08–6.09]).
  • Conclusion: Extremely low e-cigarette use among never-smokers and longer term former smokers suggest that e-cigarettes neither promote widespread initiation nor relapse among adults. Recognition of the heterogeneity of smokers, including the time since quitting, is critical to draw accurate conclusions about patterns of e-cigarette use at the population level and its potential for public health benefit or harm.

2016: Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries(Must pay to view PDF / full paper)

  • E‐cigarette use in the European Union appears to be largely confined to current or former smokers, while current use and nicotine use by people who have never smoked is rare. More than one‐third of current e‐cigarette users polled reported smoking cessation and reduction.

2017: Predicting Short-Term Uptake of Electronic Cigarettes: Effects of Nicotine, Subjective Effects, and Simulated Demand (Must pay to view PDF)

  • Mean cigarettes per day decreased by 37% when e-cigarettes were available relative to baseline. Nicotine-containing cartridges were associated with greater use and craving reduction than 0 mg. Alleviation of withdrawal symptoms and taste and enjoyment factors predicted e-cigarette use.

2017: Cohort study of electronic cigarette use: effectiveness and safety at 24 months (PDF 9 pages)

  • Of the e-cigarette users, 61.1% remained abstinent from tobacco (while 23.1% and 26.0% of tobacco-only smokers and dual users achieved tobacco abstinence).

2018 Advice From Former-Smoking E-Cigarette Users to Current Smokers on How to Use 

E-Cigarettes as Part of an Attempt to Quit Smoking 

(PDF 26 pages)

  • This study describes the advice that former-smokers who used e-cigarettes to quit smoking would offer to smokers who are considering using an e-cigarette to support an attempt to quit smoking. Vapers advised smokers to find the right combination of device, flavors and nicotine strength, continue to smoke and vape for a while if they wished, not be deterred by past failed attempts to quit smoking, and expect health to improve after they have switched to vaping. Encouraging smokers to interact with vaping peers in vape shops and in online vaping-dedicated discussion fora may help significantly more smokers switch to vaping.

2019: Association Between Electronic Cigarette Use and Smoking Reduction in France 

(Must pay to view full article or PDF) 

  • Findings  This cohort study found that, among daily smokers in France, regular (daily) electronic cigarette use is associated with a significantly higher decrease in the number of cigarettes smoked per day as well as an increase in smoking cessation attempts. However, among former smokers, electronic cigarette use is associated with an increase in the rate of smoking relapse.
  • NOTE: Article that covers above study – Adults who vape are more likely to quit cigarettes, study finds
  • “The study did find that the heightened risk of relapse disappeared in those who quit smoking more recently, which the researchers said may be due to improved e-cigarette technology.”
  • “For example, the study as a whole considered anybody who quit smoking from 2010 onward and found that, in that sample, vaping increased the risk of relapse. But when researchers only considered people who quit cigarettes as of 2013, former smokers were not more likely to relapse if they vaped.”
  • “The researchers noted in their study that “measures of plasma nicotine levels have shown that, compared with older models of [e-cigarettes], the new generation delivers higher levels of nicotine to the bloodstream,” which may make them more satisfying.”
  • “Other “technical improvements in [e-cigarettes] over time,” they said, may also explain why people who recently quit smoking and switched to e-cigarettes were less likely to relapse than those who quit earlier.”

2019: Association of prevalence of electronic cigarette use with smoking cessation and 

cigarette consumption in England: a time–series analysis between 2007 and 2017

(PDF 14 pages)

  • The increase in prevalence of e‐cigarette use by smokers in England has been positively associated with an increase in success rates of quit attempts and overall quit rates

2019 Electronic Cigarette Use and Cigarette Abstinence Over 2 Years Among U.S. Smokers in 

the Population Assessment of Tobacco and Health Study 

  • In this nationally representative longitudinal cohort study of US adult cigarette smokers, daily e-cigarette use, compared to no e-cigarette use, was associated with a 77% increased odds of prolonged cigarette smoking abstinence over the subsequent 2 years. Regular use of e-cigarettes may help some smokers to stop smoking combustible cigarettes.
  • Article: Daily e-cigarette use may help smokers quit regular cigarettes 

2019 Article: Adults who vape are more likely to quit cigarettes, study finds

  • “The study did find that the heightened risk of relapse disappeared in those who quit smoking more recently, which the researchers said may be due to improved e-cigarette technology.”
  • “For example, the study as a whole considered anybody who quit smoking from 2010 onward and found that, in that sample, vaping increased the risk of relapse. But when researchers only considered people who quit cigarettes as of 2013, former smokers were not more likely to relapse if they vaped.”
  • “The researchers noted in their study that “measures of plasma nicotine levels have shown that, compared with older models of [e-cigarettes], the new generation delivers higher levels of nicotine to the bloodstream,” which may make them more satisfying.”
  • “Other “technical improvements in [e-cigarettes] over time,” they said, may also explain why people who recently quit smoking and switched to e-cigarettes were less likely to relapse than those who quit earlier.” 

2020: Tobacco harm reduction in the 21st century (PDF 16 pages)

  • In conclusion, to reduce smoking and to save millions of lives, tobacco harm reduction in the form of cigarette substitution with low-risk products appears to be a promising path. These products, although not completely risk-free, offer an alternative to quit or die. In consideration of the available evidence, advice to tobacco smokers should include trying substitute products. The obvious fact so often overlooked is that smoking is rewarding and people like to do it. Giving smokers an alternative with efficient nicotine delivery means that they might prefer one of these products over cigarettes. 

2020: Highlights of Studies in Cardiovascular Disease Prevention Presented at the 2020 American College of Cardiology Annual Scientific Session (PDF 10 pages)

  • In E3, nicotine e-cigarettes plus counseling was superior to counseling alone for smoking cessation. Non-nicotine e-cigarettes plus counseling was also more effective compared with counseling alone though its effects on cessation were modest. This trial demonstrates the efficacy of e-cigarettes as a tool for smoking cessation compared with counseling alone.

2020: A magic bullet? The potential impact of e-cigarettes on the toll of cigarette smoking  (No link to PDF found)

  • The combination of assumptions produces 360 possible scenarios. 357 (99%) yield positive estimates of life-years saved (LYS) due to vaping by 2100, from 143,000 to 65 million. 
  • The impact of vaping is greatest when it most helps smokers who otherwise have the greatest difficulty quitting smoking.
  • Vaping is highly likely to reduce smoking-produced mortality. Still, vaping is not “the” answer to the public health crisis created by smoking. Rather, it may well be a tool to add to the armamentarium of effective tobacco control measures.
  • Harm reduction can, and many would say should, be a part of the complex formula that will eventually bring about the demise of smoking.

2020: Patterns of e-cigarette use and subsequent cigarette smoking cessation over two years (2013/2014 to 2015/2016) in the Population Assessment of Tobacco and Health (PATH) Study (PDF 29 pages)

  • Smoking cessation was more likely among frequent e-cigarette users, users of e-cigarettes in last quit attempt, and users of flavored and rechargeable devices.

2020: Using e-cigarettes for smoking cessation: evaluation of a pilot project in the North West of England (PDF 11 pages)

  • Of the 1022 participants who engaged with the pilot 614 were still engaged at 4 weeks, of whom 62% had quit smoking. Of those who still smoked tobacco at week 4, smoking had reduced from a baseline of 19.1 cigarettes/day to 8.7. Overall, 37% of those initially enrolled were confirmed to be using an e-cigarette on its own at follow-up. Successful quit was associated with occupation (unemployed, 33% vs intermediate, 47%) and residing in the less deprived quintiles of deprivation (50% vs 34% in the most deprived quintile.
  • E-cigarettes appear to be an effective nicotine replacement therapy

Race / Ethnic / Socioeconomic / Education

2016 Racial/Ethnic Differences in Electronic Cigarette Use and Reasons for Use among Current 

and Former Smokers: Findings from a Community-Based Sample  (PDF 11 pages)

  • This study found more similarities than differences among Whites, African Americans/Blacks, and Hispanics with a history of tobacco smoking.
  • African Americans/Blacks were significantly less likely to report ever-use compared to Whites and Hispanics (50% vs. 71% and 71%, respectively; p < 0.001).
  • African American/Black ever users were more likely to report plans to continue using e-cigarettes compared to Whites and Hispanics (72% vs. 53% and 47%, respectively, p = 0.01).
  •  African American/Black participants were more likely to use e-cigarettes as a cessation aid compared to both Whites (p = 0.03) and Hispanics (p = 0.48)
  • White participants were more likely to use e-cigarettes to save money compared to Hispanics (p = 0.02).

2018 Socioeconomic and Racial/Ethnic Differences in E-Cigarette Uptake Among Cigarette 

Smokers: Longitudinal Analysis of the Population Assessment of Tobacco and Health 

(PATH) Study  (PDF 9 pages)

  •  Compared with non-Hispanic Whites, non-Hispanic Black, and Hispanics were less likely to become exclusive e-cigarette users 
  •  Low-income smokers were less likely than higher-income smokers to become exclusive e-cigarette users
  • Black, Hispanic, and low-income smokers were more likely to believe e-cigarettes are more harmful than cigarettes and to have positive tobacco-related social norms.
  • Results of this study show that the exclusive use of e-cigarettes is more prevalent in higher-income and White smokers. Our data suggest that higher-income and White smokers may be more likely to use e-cigarettes as a means to quit combustible cigarettes compared with low-income and racial/ethnic minority smokers. These findings suggest that sociodemographic differences in e-cigarette uptake and use patterns may contribute to widening disparities in cigarette smoking.

2019 Socioeconomic Disparities in Electronic Cigarette Use and Transitions from Smoking. 

(Did not find a link to a PDF)

  • Furthermore, more educated smokers are more likely to switch to exclusive e-cigarette use than less educated smokers. 
  • Such differential switching may exacerbate socioeconomic disparities in smoking-related morbidity and mortality, but lower the burden of tobacco-related disease.

2020: Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence (PDF 14 pages)

  • The review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP (non-combustible nicotine products) for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups).
  • Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to: 
    • wider circumstances of socioeconomic disadvantage; 
    • lack of a perceived advantage of alternative products over smoking; 
    • and a perceived lack of information about relative harms of NCNP compared to smoking. 
  • Optimistic findings, although fewer, suggested the potential of NCNP being taken up among smokers experiencing socioeconomic disadvantage.

Regulations and Taxes 

2015: Ethical issues raised by a ban on the sale of electronic nicotine devices (Must pay to view PDF)

  • Respect for autonomy: prohibiting ENDS infringes on smokers’ autonomy to use a less harmful nicotine product while inconsistently allowing individuals to begin and continue smoking cigarettes.
  • Non‐maleficence: prohibition is supposed to prevent ENDS recruiting new smokers and discouraging smokers from quitting. It also perpetuates harm by preventing addicted smokers from using a less harmful nicotine product.
  • Beneficence: ENDS could benefit addicted smokers by reducing their health risks if they use them to quit and do not engage in dual use.
  • Distributive justice: lack of access to ENDS disadvantages smokers who want to reduce their health risks. Different national policies create inequalities in the availability of products to smokers internationally.

2016: Study: A Framework for Evaluating the Public Health Impact of E-cigarettes and Other 

Vaporized Nicotine Products (PDF 16 pages) – Article: Public health benefits of e-cigarette use tend to outweigh the harms, new study says –  Article: Top tobacco control experts to FDA: Studies of e-cigs suggest more benefit than harm 

  • Comments: “…The primary aim of tobacco control policy should therefore be to discourage cigarette use while providing the means for smokers to more easily quit smoking, even if that means switching for some time to VNPs (vaporized nicotine products) rather than quitting all nicotine use. Countries whose policies discourage VNP use run the risk of neutralizing a potentially useful addition to methods of reducing tobacco use…” 

2017 Does the Regulatory Environment for E-Cigarettes Influence the Effectiveness of 

E-Cigarettes for Smoking Cessation?  (PDF 9 pages)

  • This study shows that in a less restrictive EC regulatory environment, use of ECs during a quit attempt facilitates, but in a more restrictive environment, it inhibits, short-term sustained abstinence. The findings underscore the need for careful consideration on how best to regulate this emerging product so that EC benefits for smoking cessation are maximized and its risks to public health are minimized.

2019 E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the 

Potential Benefits of Increasing Smoking Cessation. (must pay to view whole study)

  • Potential life-years gained as a result of vaping-induced smoking cessation are projected to exceed potential life-years lost due to vaping-induced smoking initiation. These results hold over a wide range of plausible parameters
  • Our analysis strongly suggests that the upside health benefit associated with e-cigarettes, in terms of their potential to increase adult smoking cessation, exceeds their downside risk to health as a result of their possibly increasing the number of youthful smoking initiators. Public messaging and policy should continue to strive to reduce young people’s exposure to all nicotine and tobacco products. But, they should not do so at the expense of limiting such products’ potential to help adult smokers to quit.

2019: Young adult dual combusted cigarette and e-cigarette users’ anticipated responses to 

hypothetical e-cigarette market restrictions   (PDF 11 pages)

  • Conclusion: This work provides preliminary evidence that restrictive regulations regarding key EC characteristics may increase intentions to increase CC use among young adult dual EC and CC users.” (EC = E-cigarette, CC = Combustible Cigarette) 

2019: E-Cigarettes and Adult Smoking: Evidence from Minnesota (PDF 33 pages)

  • We provide some of the first evidence on how e-cigarette taxes impact adult smokers, exploiting the large tax increase in Minnesota. That state was the first to impose a tax on e-cigarettes by extending the definition of tobacco products to include e-cigarettes. This tax, which is 95% of the wholesale price, provides a plausibly exogenous deterrent to e-cigarette use.
  • Our results suggest that in the sample period about 32,400 additional adult smokers would have quit smoking in Minnesota in the absence of the tax. If this tax were imposed on a national level about 1.8 million smokers would be deterred from quitting in a ten year period. The taxation of e-cigarettes at the same rate as cigarettes could deter more than 2.75 million smokers nationally from quitting in the same period. 

2020: Are E-Cigarette Regulations Jeopardizing the Public Health? (PDF 17 pages)

  • The demonization of e-cigarettes in the U.S. is counterproductive. As part of a tobacco harm reduction strategy, the potential public health benefits from e-cigarettes are substantial. Opposition to e-cigarettes, often fueled by misleading information, curbs their use as a smoking cessation aid by millions of adults.
  • E-cigarettes are far less harmful than combustible cigarettes and constitute one of the most common — and effective — smoking cessation aids. Overzealous or poorly designed restrictions on vaping, combined with misleading information about e-cigarettes’ true health risks, are deterring smokers from pursuing a potentially life-saving alternative.
  • If cigarette use were largely replaced by vaping over a 10-year period in the U.S., it would prevent as many as 6.6 million premature deaths.
  • A report by a government agency, the Public Health of England, an agency of England’s Department of Health and Social Care, reported that most consumers who vape do so in order to stop smoking.
  • The doses of toxins contained in e-cigarettes are typically hundreds or thousands of times lower than in regular cigarettes. While non-smokers would be ill-advised to take up vaping, smokers could reap significant health benefits from switching to e-cigarettes.
  • Underage vaping by nonsmokers is rare, which supports the correlation that the rise in vaping has led to a decline in smoking among teens.Not only does the hysteria surrounding e-cigarettes endanger smokers and jeopardize public health, it also undermines the credibility of health authorities on other important issues like the coronavirus and vaccines. The American public should be told the truth about e-cigarettes.

2020: A rational approach to e-cigarettes -challenging ERS policy on tobacco harm reduction 

(PDF 11 pages)

  • We  believe  that  blanket  opposition  to  e-cigarettes  is  misguided  and  will  lead  to  a  number  of important consequences that are adverse to health. 
  • First, smokers who would otherwise have quit smoking  by  switching  to  a  lower  risk  product  will  continue  to  smoke,  and  die  prematurely  from cancer,  cardiovascular  and  respiratory  disease.  
  • Second,  people  who  have  successfully  switched  to vaping may relapse to smoking if they come to believe that there is no health benefit from vaping, and  thus  increase  their  risk  of  avoidable  morbidity  and  premature death.
  • Third,  the  pursuit  of arguments that vaping can’t help people to quit smoking, in the face of clear evidence that it does, risks undermining public trust in science.

2020: Vape shop owners/managers’ opinions about FDA regulation of e-cigarettes (No link to PDF found)

  • Vape shop owners/managers reported: 
  • 1) entering the industry with positive intentions for their customers; 
  • 2) training their personnel to adhere to regulations and provide good customer service; and 
  • 3) significant concerns about the impact of FDA regulations. With regard to the latter, participants reported mistrust of the intentions of the FDA regulations, financial implications of the regulations (particularly for small businesses), difficulty understanding and interpreting the regulations, insufficient evidence to support the regulations, negative impact on customer service, negative impact on product offerings and product innovation/advancement, and negative implications of flavor bans and/or restrictions on sale of flavors.

2020: The Effects of E-Cigarette Taxes on E-Cigarette Prices and Tobacco Product Sales: 

Evidence from Retail Panel Data (PDF 46 pages)

  • We simulate that for every one standard e-cigarette pod (a device that contains liquid nicotine in e-cigarettes) of 0.7 ml no longer purchased as a result of an e-cigarette tax, the same tax increases traditional cigarettes purchased by 6.2 extra packs. 

Public Health

2nd Hand Vapor

2012: Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality 

(Abstract only, must pay to view whole study / PDF)

  • Comparisons of pollutant concentrations were made between e-cigarette vapor and tobacco smoke samples. Pollutants included VOCs, carbonyls, PAHs, nicotine, TSNAs, and glycols.
  • Non-cancer risk analysis revealed “No Significant Risk” of harm to human health for vapor samples from e-liquids.
  • With regard to cancer risk analysis, no vapor sample from e-liquids exceeded the risk limit for either children or adults.

2014: Peering through the mist: systematic review of what the chemistry of contaminants in 

electronic cigarettes tells us about health risks  (PDF 14 pages)

(Note, this study is also listed under “Toxicity / e-cigarettes” with more details)

  • Threshold Limit Values (TLVs), were conducted under “worst case” assumptions about both chemical content of aerosol and liquids as well as behavior of vapers.
  • There was no evidence of potential for exposures of e-cigarette users to contaminants that are associated with risk to health at a level that would warrant attention if it were an involuntary workplace exposures.
  • Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.

2017 Evaluation of Chemical Exposures at a Vape Shop (Report is 30 pages)

By: U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Institute for Occupational Safety and Health

  • We collected air samples for flavoring chemicals (diacetyl, 2,3-pentanedione, 2,3-hexanedione, acetaldehyde, and acetoin), nicotine, formaldehyde, and propylene glycol. 
  • Concentrations of vaping-related chemicals in our air samples were below occupational exposure limits.

2017 Dr. Michael Siegel  – Vape Shop Air Sampling by California State Health Department

Suggests that Second Hand Vape Exposure is Minimal 

  • This study, although conducted under very high exposure conditions in a small, non-ventilated vape shop with many employees and customers vaping and clouds of vapor visible, did not document any dangerous levels of exposure to any hazardous chemical. Nicotine exposure was essentially non-existent. Formaldehyde exposure was no different than in many indoor and outdoor environments at baseline. Acetone, acetoin, other aldehydes, toluene, benzene, and xylene were not detected. Chemicals that have been associated with “popcorn lung” were also not detected by the standard method.
  • This study adds to the evidence that under real-life conditions, “secondhand vaping” does not appear to pose any significant health risks.

2018: Characterization of the Spatial and Temporal Dispersion Differences Between Exhaled E-Cigarette Mist and Cigarette Smoke (PDF 7 pages)

  • For both product categories, the particle concentrations registered following each puff were in the same order of magnitude. However, for e-cigarettes the particle concentration returned rapidly to background values within seconds; for conventional cigarettes it increased with successive puffs, returning to background levels after 30–45 minutes. Unlike for the e-cigarette devices tested, such temporal variation was dependent on the room ventilation rate. Particle size measurements showed that exhaled e-cigarette particles were smaller than those emitted during smoking conventional cigarettes and evaporated almost immediately after exhalation, thus affecting the removal of particles through evaporation rather than displacement by ventilation.

Continuum of Risk

2014: Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach (PDF 8 pages) 

  • The group defined 12 products and 14 harm criteria. Seven criteria represented harms to the user, and the other seven indicated harms to others.
  • The results of this study suggest that of all nicotine-containing products, cigarettes (and small cigars in the USA) are very much the most harmful. Interventions to reduce this pre-eminence are likely to bring significant benefits not just to users but also to non-smokers and society as a whole. Attempts to use other forms of nicotine such as ENDS and NRT to reduce cigarette smoking should be encouraged as the harms of these products are much lower.

2016: Obsolete tobacco control themes can be hazardous to public health: the need for 

updating views on absolute product risks and harm reduction  (PDF 11 pages)

  • Implications of updating the leading themes for regulation, policymaking and advocacy in tobacco control are proposed as an important next step. A new reframing can align action plans to more powerfully and rapidly achieve population-level benefit and minimize harm to eliminate in our lifetime the use of the most deadly combustible tobacco products and thus prevent the premature deaths of 1 billion people projected to occur worldwide by 2100

2016: Withholding differential risk information on legal consumer nicotine/tobacco products: The public health ethics of health information quarantines (PDF 7 pages) 

  • The straight-forward principles of harm reduction should be as uncontroversial for tobacco products as they are for alcohol, cars, air travel, children’s clothing, sexual practices, electrical goods and other goods and activities.
  • Concerns for some adverse public health effects of harm reduction products such as SLT (Smokeless Tobacco) and vape are reasonable and worth trying to minimize, but there is no current evidence that such products actually represent an imminent danger to public health overall
  • Efforts to discourage the use of tobacco/nicotine products need not be reduced, but should be done in a harm-proportionate way. Telling consumers that all product options are as bad as cigarettes is untrue and almost certainly as deadly for users as telling at-risk populations that condom use affords no protection.

2016: Ethical considerations of e-cigarette use for tobacco harm reduction (PDF 9 pages)

  • Current evidence suggests that e-cigarettes have the potential to make significant public health gains through their role as tobacco harm reduction devices. In clinical practice, physicians have an ethical duty to provide their patients with evidence-based comparative risk assessments to allow them to make informed choices with respect to their smoking status. At its core, the objective of the smoking cessation agenda should be to improve population health, which will likely require some concessions in the form of harm reduction. This entails a willingness to negotiate the tensions between utilitarian and liberal ethics in designing policy that upholds autonomy while protecting broader public health interests.

2017: Potential deaths averted in USA by replacing cigarettes with e-cigarettes (PDF 8 pages)

  • Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016.
  • The tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm.

2018: Harm Minimization andTobacco Control: ReframingSocietal Views of Nicotine Use To Rapidly Save Lives (PDF 25 pages)

  • FDA’s Gottlieb & Zeller state: “Nicotine,though not benign, is not directly responsible for the tobacco-caused cancer, lung disease and heart disease that kill hundreds of thousands of Americans each year”
  • Inhalation of the toxic smoke produced by combusting tobacco products,primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do notcombust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible.
  • Most reviews of toxicological, clinical, and epidemiological evidence indicate that the chemicals found in e-cigarettes, when used as intended, are far fewer and well below levels seen in cigarette smoke
  • Studies in humans have also documented improved physiological outcomes, including reduced blood pressure, improved lung function, andlower disease symptoms, among smokers who switched to e-cigarettes 
  • E-cigarettes are much less dependence-producing than are cigarettes
  • The potential harm of e-cigarettes falls in the low range on the continuum

2020: E-cigarettes and their impact on health: from pharmacology to clinical implications (PDF 20 pages)

  • Despite many areas of ambiguity, current evidence suggest that e-cigarettes are less harmful than combustible products, but this only applies to smokers who completely switched to e-cigarettes. Thus, e-cigarettes still hold a great potential to reduce incidences of tobacco-related diseases and could be a part of the strategy to reduce the damage caused by smoking. Therefore, mechanisms should be developed to protect young people from using e-cigarettes but support smokers in their decisions to quit smoking with e-cigarettes.

2020: The ethics of tobacco harm reduction: An analysis of e-cigarette availability from the perspectives of utilitarianism, bioethics, and public health ethics (pre-publication, no PDF available at this time) 

  • Much evidence suggests e-cigarettes are substantially less harmful than combustible cigarettes. E-Cigarette Availability (ECA) involves making e-cigarettes available to allow smokers to switch to them, and informing smokers of the lower risks of e-cigarettes vis-à-vis smoking. 
  • First, ECA is supported by a public health ethics framework. ECA is a population-level intervention consistent with respecting individual autonomy by using the least restrictive means to accomplish public health goals, and it supports equity and justice. Second, ECA is supported by four principles that form a biomedical ethics framework. By reducing smokers’ health risks and not harming them, ECA fulfills principles of beneficence and non-maleficence. Because ECA allows smokers to make informed health decisions for themselves, it fulfills the principle requiring respect for persons and their autonomy.
  • ECA can also advance justice by providing a harm reduction alternative for disadvantaged groups that disproportionately bear the devastating consequences of smoking. Policies of differential taxation of cigarettes and e-cigarettes can facilitate adoption of less harmful alternatives by those economically disadvantaged.
  • We conclude that public health and biomedical ethics frameworks are mutually reinforcing and supportive of ECA as a tobacco harm reduction strategy. 

Dependence (Addiction, Abuse) vs Harm / Harm Reduction – Ecigs and Nicotine

2011: Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a 

repeat of past mistakes?  (16 pages – Journal article)

  • We conclude that electronic cigarettes show tremendous promise in the fight against tobacco-related morbidity and mortality. By dramatically expanding the potential for harm reduction strategies to achieve substantial health gains, they may fundamentally alter the tobacco harm reduction debate.

2012: Dependence on Tobacco and Nicotine Products: A Case for Product-Specific Assessment 

(PDF 9 pages) 

  • Conclusion: “The other suggestion made is that when the totality of the dependence is measured, different forms of tobacco/nicotine products probably have different potential for dependence development. There might be a continuum of dependence where in one end, we find the cigarette and in the other end, NR products and particularly the patch formulation. If a particular product is far from cigarettes and close to NR on the continuum of harm and at the same time closer to cigarettes than NR on the continuum of dependence, this product may have considerable success in reducing the public health costs associated with cigarette use.”

2012: Clinical laboratory assessment of the abuse liability of an electronic cigarette (Abstract 

only, myst pay to view whole stud / PDF)

  • Electronic cigarettes can deliver clinically significant amounts of nicotine and reduce cigarette abstinence symptoms and appear to have lower potential for abuse relative to traditional tobacco cigarettes.

2013: A fresh look at tobacco harm reduction: the case for the electronic cigarette 

(PDF 11 pages)

  • “Thus even if 50% of the non-smoking population should decide to addict itself to nicotine via an E-cig, the associated disease risks, if any, would be minimal. Thus, “abuse liability” is a moot point in this context.”

2014: Dependence levels in users of electronic cigarettes, nicotine gums and tobacco cigarettes (PDF 15 pages)

  • E-cigarettes may be as or less addictive than nicotine gums, which themselves are not very addictive.

2017: E-cigarettes: Impact of E-liquid Components and Device Characteristics on Nicotine Exposure (PDF 22 pages)

  • Given the large range of factors that can impact nicotine delivery, not only within the e-liquids but also in the hardware and user behavior, any regulatory framework intended to moderate nicotine exposure in users may not achieve its intended aim if it is solely limited to a regulation of the nicotine concentration of the e-liquid.

2017: A comparison of nicotine dependence among exclusive E-cigarette and cigarette users in the PATH study (Must pay to view PDF)

  • Cigarette smokers are more likely to consider themselves addicted, to have strong cravings, and to feel like they really needed to use their product. Cigarette smokers found it more difficult not to use in places where prohibited.
  • E-cig users report less dependence on their product than cigarette smokers. E-cig users report a longer time-to-first-use after waking.
  • These results are consistent with previous studies, in finding that exclusive daily e-cigarette users are less dependent on their respective product than comparable cigarette smokers.

2017: Evaluating nicotine dependence levels in e-cigarette users  (no link to PDF found)

  • Results showed that e-cigarette users scored lower than cigarette smokers in both FTND (Fagerström test for nicotine dependence) and all NDSS (nicotine dependence syndrome scale) subscales. Our findings extend previous research on e-cigarette use and nicotine addiction and suggest that e-cigarette users are less dependent on nicotine than current tobacco cigarette smokers.

2020: Dependence on e‐cigarettes and cigarettes in a cross‐sectional study of US adults (PDF 8 pages)

  • Among current users, dependence on e‐cigarettes was significantly lower than dependence on cigarettes, in within‐subjects comparisons among dual users of both e‐cigarettes and cigarettes, and in separate groups of e‐cigarette users and cigarette smokers, and among both daily and non‐daily users of each product.
  • Among former users, residual symptoms were significantly lower for e‐cigarettes than cigarettes, both among former dual users and among users of one product. 
  • The highest level of e‐cigarette dependence was among e‐cigarette users who had stopped smoking.
  • Use of e‐cigarettes appears to be consistently associated with lower nicotine dependence than cigarette smoking.

Elderly

2019 Article: New smoking statistics shows ‘gray vaping’ is on the rise in the UK 

2019 PDF of Study (43 pages) NHS Statistics on Smoking

Mental Health

2011: Smoking Cessation with E-Cigarettes in Smokers with a Documented History of 

Depression and Recurring Relapses  (PDF 4 pages)

  • The most important message from this case series is that these individuals were able to quit and to remain abstinent for at least 6 months after taking up an electronic cigarette. This is the first time that objective measures of smoking cessation are reported in smokers, suffering from depression, who quit after experimenting with the e-cigarette. This is quite outstanding in consideration of the fact that this result was accomplished by highly addicted smokers who repeatedly failed professional smoking cessation assistance without the support of recommended nicotine dependence treatments and smoking cessation counselling.

2013: Impact of an Electronic Cigarette on Smoking Reduction and Cessation in Schizophrenic 

Smokers: A Prospective 12-Month Pilot Study (PDF 16 pages)

  • Even with intensive smoking cessation management programs specifically designed for patients with schizophrenia, quit rates are low. Although not formally regulated as a pharmaceutical product, the e-cigarette can help smokers with schizophrenia to reduce their cigarette consumption or remain abstinent and reduce the burden of smoking-related morbidity and mortality, particularly in schizophrenic patients who smoke

2014: Use of e-cigarettes by individuals with mental health conditions   (PDF 6 pages) 

  • Individuals with mental health conditions (MHC) have disproportionately high tobacco-related morbidity and mortality due to high smoking prevalence rates. As high consumers of cigarettes, smokers with MHC may consider using e-cigarettes as an alternative form of nicotine delivery.
  • Individuals with MHC were more likely to have tried e-cigarettes (14.8%) and to be current users of e-cigarettes (3.1%) than those without MHC (6.6% and 1.1%, respectively; p<0.01). Ever smokers with MHC were also more likely to have tried approved pharmacotherapy (52.2% vs 31.1%, p<0.01) and to be currently using these products (9.9% vs 3.5%, p<0.01) than those without MHC. Additionally, current smokers with MHC were more susceptible to future use of e-cigarettes than smokers without MHC (60.5% vs 45.3%, respectively, p<0.01).
  • Smokers with MHC are differentially affected by the rise in popularity of e-cigarettes. Clinical interventions and policies for tobacco control on e-cigarettes should take into account the possible outcomes and their implications for this priority population.

2020: E-cigarette use and associated factors among smokers with severe mental illness (Must 

pay to view PDF)

  • Among participants, mean age was 46 years, the majority (70.3%) had tried an e-cigarette. Among those who had ever tried an e-cigarette, over half (54.6%) reported the reason was to quit smoking, while 13.9% reported that the reason was to reduce smoking.

2020: A qualitative study of the views about smoking, licensed cessation aids and e-cigarettes in people with schizophrenia spectrum disorders (must pay to view full study / PDF)

  • There is a need to find ways of making traditional cigarettes less appealing and alternative less harmful nicotine products (licensed and unlicensed) more appealing and accessible to this group of high risk smokers.

Never Smokers

2016: Visible Vaping: E-Cigarettes and the Further Denormalization of Smoking (PDF 6 pages)

  • Visible vaping was commonly reported by interviewees who typically interpreted such vaping as indicating that the individual was seeking to reduce or cease his or her smoking. Whilst the sight of someone using an e-cigarette could stimulate curiosity on the part of non-smokers as to what the experience of vaping was like there was little indication that our sample of non-smokers were intending taking up vaping on a regular basis. There were indications from our interviews that visible vaping had resulted in either no change in what individuals assessed as their likelihood of to smoke and for a minority of interviewees visible vaping had resulted in a reduced likelihood of smoking as assessed by interviewees.
  • To the extent that electronic cigarette use remains distinguishable from smoking combustible cigarettes there is a possibility that vaping may be associated with further denormalization of smoking.

2017: Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who 

have never smoked  (PDF 9 pages)

  • In a small sample of young-adult never-smoking, daily EC users who were carefully followed for approximately 3½ years, we found no decrements in spirometric indices, development of respiratory symptoms, changes in markers of lung inflammation in exhaled air or findings of early lung damage on HRCT, when compared with a carefully matched group of never-smoking non-EC users. Even the heaviest EC users failed to exhibit any evidence of emerging lung injury as reflected in these physiologic, clinical or inflammatory measures. Moreover, no changes were noted in blood pressure or heart rate. Since the EC users who we studied were never smokers, potential confounding by inhalation of combustion products of tobacco were obviated.
  • While the sample size was small, the results of this study may provide some preliminary evidence that long-term use of ECs is unlikely to raise significant health concerns in relatively young users.

2020: Electronic Cigarette Use Among U.S. Adults, 2018 ( PDF 8 pages)

  • In 2018, 34 million U.S. adults were current smokers, and 55 million were former cigarette smokers for any duration (5). E-cigarette use was highest among current smokers and former smokers who quit cigarettes within the past year and those who quit 1–4 years ago. The percentages who had ever used an e-cigarette or who were current e-cigarette users declined among former smokers who had gone longer without smoking cigarettes and was lowest among those who never smoked cigarettes. 

Pregnancy

2017: Indoor E-cigarette Restrictions Increase Prenatal Smoking (Article) The effect of 

e-cigarette indoor vaping restrictions on adult prenatal smoking and birth outcomes (Study) (Must pay to view whole study or PDF)

  • Our panel model results suggest that adoption of a comprehensive indoor vaping restriction increased prenatal smoking by 2.0 percentage points.
  • Places with indoor e-cigarette restrictions slowed the downward trend in tobacco cigarette use in pregnant women by 30 percent compared to places with no e-cigarette restrictions.

2017: Correlates of Electronic Cigarettes Use Before and During Pregnancy (No link to PDF found)

  • The study also shows that electronic cigarettes are commonly used as a smoking cessation aid in women of reproductive age. The greater likelihood of electronic cigarette use compared to proven adjunctive smoking treatments suggests that electronic cigarettes should be examined as a potential aid to cessation in this population.

2019: E-cigarette Regulations Increase Prenatal Cigarette Use Among Teen Smokers, Study 

Shows (Article) E-cigarette minimum legal sale age laws and traditional cigarette use 

among rural pregnant teenagers (Study) (Must pay to view PDF)

  • Teenagers under 18 could legally purchase e-cigarettes until states passed minimum legal sale age laws. These laws may have curtailed teenagers’ use of e-cigarettes for smoking cessation. 
  • These results suggest that the laws reduced cigarette smoking cessation during pregnancy rather than causing new cigarette smoking initiation. Our results may indicate an unmet need for assistance with smoking cessation among pregnant teenagers.

2020: Potential effects of using non-combustible tobacco and nicotine products during 

pregnancy: a systematic review  (PDF 12 pages)

  • This review demonstrates that the evidence does not support denying pregnant women the use of smoke-free products if the alternative is that she would continue to smoke.

2020: Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study (PDF 13 pages)

  • Smoking in pregnancy causes considerable harm, including increased risk of low birthweight, preterm delivery and stillbirth. 
  • Positive beliefs about vaping, particularly in comparison to smoking and becoming a confident vaper, were viewed as ways to overcome potential or experienced barriers to vaping. Our research findings may help develop interventions to assist women who have tried to stop smoking but have not quit and would otherwise continue to smoke during pregnancy.

2020: Smoking and use of electronic cigarettes (vaping) in relation to preterm birth and small-for-gestational-age in a 2016 U.S. national sample (Must pay to view PDF)

  • These findings suggest that vapers during pregnancy had similar risk of preterm as non-users but still had elevated risk for restricted fetal growth.

2020: Electronic cigarettes and obstetric outcomes: a prospective observational study (Must pay to view PDF)

  • The birthweight of infants born to EC users is similar to that of non‐smokers, and significantly greater than cigarette smokers. Dual users of both cigarettes and EC have a birthweight similar to that of smokers.

Perception – safety vs harm – effects on use

2014 Characteristics, Perceived Side Effects and Benefits of Electronic Cigarette Use: A 

Worldwide Survey of More than 19,000 Consumers   (PDF 18 pages)

  • In conclusion, in this large sample of dedicated EC users, it seems that ECs are used as long-term substitutes to smoking. They can be effective even in subjects who are highly dependent on smoking and are heavy smokers. Mild temporary side-effects and significant benefits are reported by this population. Motivation for using ECs comes from their expected less harmful potential compared to smoking.

2020: Perception of the relative harm of electronic cigarettes compared to cigarettes amongst US adults from 2013 to 2016: analysis of the Population Assessment of Tobacco and Health (PATH) study data (PDF 12 pages)

  • In this study, the proportion of US adults who incorrectly perceived e-cigarettes as equal to, or more, harmful than cigarettes increased steadily regardless of smoking or vaping status. Current adult smokers appear to be poorly informed about the relative risks of e-cigarettes yet have potentially the most to gain from transitioning to these products. The findings of this study emphasise the urgent need to accurately communicate the reduced relative risk of e-cigarettes compared to continued cigarette smoking and clearly differentiate absolute and relative harms.
  • The lack of accurate and consistent messaging from both public health agencies and the media may be contributing to public, and more specifically adult smokers’, perceptions about the relative risk of nicotine when decoupled from combustion and tobacco smoke.
  • Confusion may potentially be discouraging adult smokers from using alternative, less hazardous products which may ultimately result in a missed opportunity to positively impact health at both an individual and population level.

2020: Association between changes in harm perceptions and e-cigarette use among current tobacco smokers in England: a time series analysis (PDF 10 pages)

  • There is a decreasing trend in the proportion of individuals who perceive e-cigarettes to be less harmful than conventional cigarettes across the UK, Europe and the US.
  • For every 1% decrease in the mean prevalence of current tobacco smokers who endorsed the belief that e-cigarettes are less harmful than combustible cigarettes, the mean prevalence of e-cigarette use decreased by 0.48% 
  • Between 2014 and 2019 in England, at the population level, monthly changes in the prevalence of accurate harm perceptions among current tobacco smokers were strongly associated with changes in e-cigarette use.

2020: NEWS THAT TAKES YOUR BREATH AWAY: RISK PERCEPTIONS DURING AN OUTBREAK OF VAPING-RELATED LUNG INJURIES (PDF – 30 pages)

  • The  increase  in  e-cigarette  risk  perceptions  might  discourage  adult  smokers  from using e-cigarettes  as  a way  to  quit  smoking,  despite  evidence  from a  clinical trial  that  ecigarettes  are  a more  effective  cessation  method  than  FDA-approved products  such  as  the nicotine  patch.
  • Our econometric results suggest that the immediate impact of the first information shock was to increase the fraction of respondents who perceived e-cigarettes as more harmful than smoking by about 16 percentage points.   More  targeted advice  about  the  risks  of  THC  e-cigarettes (vs nicotine products)  might have  more  effectively  reduced  the  use  of  those  products,  potentially  preventing  EVALI  cases.

Propylene Glycol

1942: THE BACTERICIDAL ACTION OF PROPYLENE GLYCOL VAPOR ON 

MICROORGANISMS SUSPENDED IN AIR. I (PDF 21 pages) 

  • It has been found that propylene glycol vapor dispersed into the air of an enclosed space produces a marked and rapid bactericidal effect on microorganisms introduced into such an atmosphere in droplet form. Concentrations of 1 gm. of propylene glycol vapor in two to four million cc. of air produced immediate and complete sterilization of air into which pneumococci, streptococci, staphylococci, H. influenzae, and other microorganisms as well as influenza virus had been sprayed….

2009: Propylene glycol in e cigarettes might keep us healthy, says researchers 

  • “Propylene glycol, the primary ingredient in the electronic cigarette cartridge, may be a powerful deterrent against pneumonia, influenza, and other respiratory diseases when vaporized and inhaled according to a study by Dr. Oswald Hope Robertson. Decades before the e cigarette was invented, a study was conducted by Dr. Robertson of the University of Chicago’s Billings Hospital in 1942 on inhalation of vaporized propylene glycol in laboratory mice. A more in-depth article was printed in the 1942 issue of TIME Magazine http://www.time.com/time/magazine/article/0,9171,932876,00.html for November 16th. “Dr. Robertson placed groups of mice in a chamber and sprayed its air first with propylene glycol, then with influenza virus. All the mice lived. Then he sprayed the chamber with virus alone. All the mice died.””
  • The researchers also found that “the propylene glycol itself was a potent germicide. One part of glycol in 2,000,000 parts of air would–within a few seconds–kill concentrations of air-suspended pneumococci, streptococci and other bacteria numbering millions to the cubic foot.”

Weight 

2017: Could Vaping be a New Weapon in the Battle of the Bulge? (PDF 14 pages)

  • Obesity is set to overtake tobacco smoking in many countries as the primary cause of several high-cost diseases. Tobacco smoking mitigates weight gain through nicotine’s effect on the brain and metabolism.
  • There have been some reports among vapers that vaping is helping to mitigate weight gain after stopping smoking and or vaping is helping them to control their weight. There are several potential mechanisms by which vaping, in addition to the direct effects of nicotine, could facilitate weight control, these include taste perception, physical mouthfeel, and sensation and behavioral replacement. 

2018: Lack of Substantial Post-Cessation Weight Increase in Electronic Cigarettes Users  

(PDF 13 pages)

  • Conclusion: Within the study limitations, EC use may help smokers attenuate cigarette consumption or remain abstinent, as well as reduce their post-cessation weight increase. The potential role of the e-vapour category for harm minimization in relation to tobacco and/or food abuse requires confirmation from larger prospective studies. Moreover, the observed lack of post-cessation weight gain in those who reduced substantially cigarette consumption by switching to ECs (i.e., dual users) is an interesting finding and calls for further research investigating the role of nicotine in weight control. Meanwhile, these preliminary findings should be communicated to smokers and particularly to weight-conscious smokers intending to quit.
  • By combining substantial reduction of smoking with prevention of post-cessation weight gain, EC-based interventions may promote an overall improvement in quality of life. Considering that the negative effects of weight increase could overshadow the health benefits of smoking abstinence, it is important to stimulate more research in this area.” 

2018: E-cigarettes and Weight Loss—Product Design Innovation Insights From Industry Patents (PDF 5 pages)

  • E-cigarettes may be presented to cigarette users as a possible solution to support smoking cessation and address the fear of weight gain. 

Youth & Young Adults

Gateway

2015: The Impact of Flavor Descriptors on Nonsmoking Teens’ and Adult Smokers’ Interest in Electronic Cigarettes (PDF 8 pages) 

  • Nonsmoking teens’ interest in e-cigarettes was very low. Adult smokers’ interest was significantly higher overall and for each flavor. 
  • Teen interest did not vary by flavor, but adult interest did.
  • Past-30-day adult e-cigarette users had the greatest interest in e-cigarettes, and their interest was most affected by flavor. 
  • Nonsmoking teens who had never tried e-cigarettes had the lowest interest, followed by adults who had never tried e-cigarettes

2019 The Impact of Electronic Cigarettes on Cigarette Smoking By Americans and Its Health 

and Economic Implications  (PDF 50 pages) 

  • In this study, we examined the growing use of electronic cigarettes and its implications. The wide use of e-cigarettes is a very recent development, and issues regarding their long-term effects and significance cannot be fully analyzed at this time. Using CDC and other data covering the last decade, however, we examined the relationship between the recent sharp increase in e-cigarette use among Americans and the contemporaneous acceleration in the declining rate of cigarette smoking. We found that the sharp increase in e-cigarette use across many groups can explain as much as 70 percent of the accelerating decline in smoking rates. We also found no reasonable evidential basis for concerns that e-cigarettes are a gateway to cigarette smoking. We further found that e-cigarettes are highly effective in helping people stop smoking cigarettes.
  • Finally, we analyzed the impact of the sharp increase in e-cigarette use and the accelerating decline in cigarette smoking on healthcare costs and economic productivity. We found that while e-cigarette users incur lower healthcare costs than cigarette smokers or ex-smokers, the longer lifespans of e-cigarette users and ex-smokers who used e-cigarettes to quit smoking result in higher lifetime healthcare costs. However, we also found that the value of the additional years of life associated with using e-cigarettes instead of smoking is much greater than the additional healthcare costs. Lastly, we found that the increase in e-cigarette use and the associated reduction in smoking rates results in large productivity benefits, mainly from lower rates of illness.

2020: Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study (PDF 9 pages)

  • In conclusion, this matched control analysis of NYTS data from 2014 to 2017 suggests that for adolescents initiation with e-cigarettes is associated with a reduced risk of subsequent cigarette smoking compared with initiators with other combustible and non-combustible tobacco products use, and propensity score matched adolescents without initial e-cigarette use. This suggests that, over the time period considered, e-cigarettes were unlikely to have acted as an important gateway towards cigarette smoking and may, in fact, have acted as a gateway away from smoking for vulnerable adolescents; this is consistent with the decrease in youth cigarette smoking prevalence over the same time period that youth e-cigarette use increased between 2014 and 2017.

Youth Use / Risky Behaviors / ACE’s

2013: Adolescent Males’ Awareness of and Willingness to Try Electronic Cigarettes (must pay to 

view PDF)

  • Only two participants (< 1%) had previously tried e-cigarettes. 
  • Among those who had not tried e-cigarettes, most (67%) had heard of them. Awareness was higher among older and non-Hispanic adolescents. 
  • Nearly 1 in 5 (18%) participants were willing to try either a plain or flavored e-cigarette, but willingness to try plain versus flavored varieties did not differ. 
  • Smokers were more willing to try any e-cigarette than nonsmokers (74% vs. 13%; OR 10.25, 95% CI 2.88, 36.46). 
  • Nonsmokers who had more negative beliefs about the typical smoker were less willing to try e-cigarettes (OR .58, 95% CI .43, .79).

2014: Parent, Peer, and Executive Function Relationships to Early Adolescent E-Cigarette Use: 

A Substance Use Pathway? (PDF 15 pages) 

  • Lifetime use prevalence was 11.0% for e-cigarettes, 6.8% for cigarettes, and 38.1% for alcohol. Free lunch and age were marginally related to e-cigarette use (p<.10). Parent e-cigarette ownership was associated with the use of all substances, while peer use was associated with gateway drug use (p’s<.05-.001). EF (Executive Function) deficits were associated with the use of all substances five times more likely than others to use e-cigarettes and over twice as likely to use gateway drugs.
  • E-cigarette and gateway drug use may have common underlying risk factors in early adolescence, including parent and peer modeling of substance use, as well as EF deficits. Future research is needed to examine longitudinal relationships of demographics, parent and peer modeling, and EF deficits to e-cigarette use in larger samples, trajectories of e-cigarette use compared to use of other substances, and the potential of EF skills training programs to prevent e-cigarette use.

2015: Associations between e-cigarette access and smoking and drinking behaviours in 

teenagers   (PDF 9 pages)

  • Results: “One in five participants reported having accessed e-cigarettes (19.2%). Prevalence was highest among smokers (rising to 75.8% in those smoking >5 per day), although 15.8% of teenagers that had accessed e-cigarettes had never smoked conventional cigarettes (v.13.6% being ex-smokers). E-cigarette access was independently associated with male gender, having parents/guardians that smoke and students’ alcohol use. Compared with non-drinkers, teenagers that drank alcohol at least weekly and binge drank were more likely to have accessed e-cigarettes (adjusted odds ratio [AOR] 1.89, P < 0.001), with this association particularly strong among never-smokers (AOR 4.59, P < 0.001). Among drinkers, e-cigarette access was related to: drinking to get drunk, alcohol-related violence, consumption of spirits; self-purchase of alcohol from shops or supermarkets; and accessing alcohol by recruiting adult proxy purchasers outside shops.”

2016: E-Cigarette Uptake Amongst UK Youth: Experimentation, but Little or No Regular Use in 

Nonsmokers 

  • Letter 

2016: Survey on the use of electronic cigarettes and tobacco among children in middle and 

high school   (PDF not found) 

  • RESULTS: Among the students, 56% had tried an electronic cigarette at least once (boys: 59.9%, girls: 49.3%; ranging from 31.3% for the 8th grade students to 66.1% for the 12th grades). However, only 3.4% reported that they used electronic cigarettes every day. Initiation of e-cigarette use in these teenagers was principally due to use by friends or triggered by curiosity and they usually choose fruit or sweet flavours initially. The majority could not give the concentration of nicotine in e-cigarettes that they used. Moreover, 61.5% of the students had ever tried tobacco and 22.3% were daily smokers. Our study found a strong link between vaping and smoking. 80% of the students who had ever tried conventional cigarettes (94% for the daily smokers) had also tried an electronic cigarette, versus 16% of the students who have never smoked. Few students (6.2%) used electronic cigarettes without smoking tobacco too. Usually, they have tried tobacco before trying an electronic cigarette. Only tobacco smokers seem to smoke electronic cigarettes with nicotine.
  • CONCLUSION: Although our study shows that teenagers frequently try electronic cigarettes, it does not prove, for the moment, that vaping itself usually leads to nicotine addiction. However, as most of the teenagers are unable to tell if the electronic cigarette they are testing contains nicotine, it raises the possibility that they could be vulnerable to manipulation by the tobacco industry.

2016: Nicotine concentration of e-cigarettes used by adolescents (Must pay to view PDF)

  • Adolescents reported using nicotine-free e-liquid (28.5%), nicotine e-liquid (37.4%), or not knowing their e-liquid nicotine concentration (34.1%). 
  • Nicotine users comprised more smokers and heavier e-cigarette users compared to nicotine-free e-liquid users and those who did not know their nicotine concentration. 

2019: Blog: The 2018 American Teen Vaping Epidemic, Recalculated 

2019:  Epidemic of Youth Nicotine Addiction?  What does the National Youth Tobacco Survey 

reveal about high school e-cigarette use in the USA? By Martin J Jarvis, Robert J West, Jamie Brown

  • Shows the relation of youth usage to youth that had a previous addiction to cigarettes

2020: Up in Smoke: Exploring the Relationship between Bullying Victimization and E-Cigarette Use in Sexual Minority Youths  (Must pay to view full paper / PDF)

  • Conclusions/Importance: These findings suggest that sexual minority students who report cyberbullying victimization may use cigarette and e-cigarette products more than their non-cyberbullied peers. 

2020: Changes from 2017 to 2018 in e-cigarette use and in ever marijuana use with e-cigarettes among US adolescents: analysis of the National Youth Tobacco Survey (Must pay to view PDF)

  • Frequent and daily e-cigarette use was by far lower in never-smokers compared with ever-smokers.

2020: ‘Vaping and fidget-spinners’: A qualitative, longitudinal study of e-cigarettes in adolescence (PDF 8 pages)

  • Vaping in the study represented a time-limited trend rather than a steady user pattern.
  • Drivers out of vaping were changes in peer-group perceptions, diminished novelty and lack of addiction as the youth vaped non-nicotine-containing e-liquids.
  • In this study I have found evidence that e-cigarettes or vaping devices can represent fashionable experimentation rather than steady user patterns. 

Youth and Regulations

2015: Study: How does electronic cigarette access affect adolescent smoking?  

(Must pay to view full text / PDF) 

  • Abstract: “Understanding electronic cigarettes’ effect on tobacco smoking is a central economic and policy issue. This paper examines the causal impact of e-cigarette access on conventional cigarette use by adolescents. Regression analyses consider how state bans on e-cigarette sales to minors influence smoking rates among 12 to 17 year olds. Such bans yield a statistically significant 0.9 percentage point increase in recent smoking in this age group, relative to states without such bans. Results are robust to multiple specifications as well as several falsification and placebo checks. This effect is both consistent with e-cigarette access reducing smoking among minors, and large: banning electronic cigarette sales to minors counteracts 70 percent of the downward pre-trend in teen cigarette smoking for a given two-year period.” 

2016: Study The influence of electronic cigarette age purchasing restrictions on adolescent 

tobacco and marijuana use  (Must pay to view full text / PDF)

  • Conclusion: “We document a concerning trend of cigarette smoking among adolescents increasing when ENDS become more difficult to purchase.”

2019: E-cigarette Regulations Increase Prenatal Cigarette Use Among Teen Smokers, Study 

Shows (Article) E-cigarette minimum legal sale age laws and traditional cigarette use 

among rural pregnant teenagers (Study) (Must pay to view PDF)

  • Teenagers under 18 could legally purchase e-cigarettes until states passed minimum legal sale age laws. These laws may have curtailed teenagers’ use of e-cigarettes for smoking cessation. 
  • These results suggest that the laws reduced cigarette smoking cessation during pregnancy rather than causing new cigarette smoking initiation. Our results may indicate an unmet need for assistance with smoking cessation among pregnant teenagers.

2020: (Paper) Perverse Psychology How Anti-Vaping Campaigners Created the Youth Vaping “Epidemic” (PDF 28 pages) 

  • It is reasonable for anti-tobacco advocates to worry about youth experimentation with nicotine, but the evidence is clear that their interventions have backfired and made the problem worse. Their attempts to dissuade teenagers from vaping increased their awareness of the behavior, made it more attractive, and convinced them that everyone around them was doing it.
  • Anti-tobacco advocates argue that the government can end the “epidemic” by raising the minimum tobacco age to 21, banning non-tobacco e-cigarette flavors, and increasing funding for anti-vaping education. But, as this paper has demonstrated, these measures will not only fail, they will actually make matters worse by increasing the coolness of vaping and youth attraction to it.
  • Teen vaping did not escalate despite the increased anti-vaping messaging. Adolescents’ curiosity and subsequent experimentation with vaping rose because of anti-vaping messaging.

Young Adults

2015: Risky behaviors, e-cigarette use and susceptibility of use among college students. 

(Must pay to view full text / PDF) 

  • Conclusion: “More e-cigarette users report use of another nicotine product besides e-cigarettes as the first nicotine product used; this should be considered when examining whether e-cigarette use is related to cigarette susceptibility. Involvement in risky behaviors is related to e-cigarette use and susceptibility to e-cigarette use. Among college students, e-cigarette use is more likely to occur in those who have also used other tobacco products, marijuana, and/or alcohol.”

2015: Changes in use of cigarettes and non-cigarette alternative products among college 

students. (Must pay to access PDF) 

  • RESULTS: The most prevalent products used by the entire sample at Wave 1 were cigarettes, followed by hookah, cigars/cigarillos/little cigars, and electronic cigarettes (e-cigarettes). At Wave 2, prevalence of e-cigarette use surpassed use of cigars/cigarillos/little cigars. Snus and chew/snuff/dip were relatively uncommon at both waves. Examination of change in use indicated that e-cigarette use increased across time among both current cigarette smokers and non-cigarette smokers. Prevalence of current e-cigarette use doubled across the 14-month period to 25% among current smokers and tripled to 3% among non-cigarette smokers. Hookah use also increased across time, but only among non-cigarette smokers, whereas it decreased among current cigarette smokers. Use of all other non-cigarette alternatives remained unchanged across time. Logistic regression analysis was used to examine the socio-demographic predictors of Wave 2 e-cigarette use, the only product that increased in use among both current cigarette smokers and non-cigarette smokers. Results indicated that Wave 1 current cigarette use and Wave 1 current e-cigarette use, but not gender, age, or race/ethnicity, were significantly associated with Wave 2 e-cigarette use.

2015: Electronic Cigarette Trial and Use among Young Adults: Reasons for Trial and Cessation 

of Vaping   (PDF 8 pages) 

  • Conclusion: …”We also see that about one third of former smokers and over 7% of never smokers report having tried e-cigarettes, and current use is 10% and 2% in these groups, respectively. Similar findings have led others to raise concerns that e-cigarette use is a threat to public health because it can lead to combustible tobacco use, presumably among those who otherwise would not have become smokers [2]. However, it is extremely rare for e-cigarette use to be the first exposure to nicotine in young adults. It was reported by fewer than 0.4% of the never smokers, and none of the current and former smokers. This may be a cohort effect, and e-cigarette use as the initial exposure to nicotine may become more common as younger cohorts, who are experimenting with vaping at higher and higher rates, mature [19]. Nevertheless, in this cohort, 99.6% of young adult never-smokers who tried e-cigarettes had previously used or experimented with another form of tobacco, suggesting that in these young adults tobacco is a gateway to e-cigarettes, rather than the reverse.”…

2016: A Randomized Trial Comparing the Effect of Nicotine Versus Placebo Electronic 

Cigarettes on Smoking Reduction Among Young Adult Smokers  (No link for a PDF was 

found)

  • Study subjects (n = 99) were young adult (21–35), current smokers
  • A diverse young adult sample of current everyday smokers, who were not ready to quit, was able to reduce smoking with the help of ECs.

2020: Adverse Childhood Experiences (ACE) and Health Indicators in a Young Adult, College Student Sample: Differences by Gender (Must pay to view PDF)

  • Approximately 51.7% of the sample reported at least one ACE
  • We observed graded relationships between levels of ACE exposure and physical, mental, and behavioral health indicators including cigarette use, e-cigarette use, drinking and driving, obesity, lifetime depression, suicide ideation and attempt, non-suicidal self-injury, and lack of restful sleep.
  • ACE-exposed females reported worse mental health status than ACE-exposed males while males reported more substance use than females. Most outcomes did not vary significantly by sex.

*** See Also

Regulations

2019: Young adult dual combusted cigarette and e-cigarette users’ anticipated 

responses to hypothetical e-cigarette market restrictions

Section 2: Smokeless Tobacco Products

HNB – Heat Not Burn

Loose Tobacco (Chew / Dip)

Snus

Tobacco Pouches (not snus)

Section 3: Nicotine Products with no Tobacco (Not medical products approved for cessation)

Lozenges

Pouches

2020: Initial Information on a Novel Nicotine Product

Toothpicks

Section 4: Nicotine Replacement Therapy (NRT)

1997: Environmental Assessment for Nicotine Inhaler / FONSI

2001: The nicotine inhaler: clinical pharmacokinetics and comparison with other nicotine 

treatments. (Must pay to view PDF)

  • Despite the ‘cigarette-like’ appearance of the inhaler and the associated sensory/ritual elements, little treatment dependence or abuse has been reported. 

2006: Nicotine replacement therapy for long‐term smoking cessation: a meta‐analysis 

(PDF 6 pages)

  • This review focused on the long‐term impact of the current “one‐shot” therapeutic approach to treatment with NRT and found significant but modest effects. Although such treatment is still likely to be highly cost‐effective in terms of life‐years gained, the substantial amount of relapse observed even after a year of abstinence, and the fact that more than 90% of those treated do not succeed, questions whether this therapeutic approach is the most appropriate. Our results support the notion that nicotine addiction, like others, should be viewed as a chronic recurring disease of the brain, and that its treatment should probably be closer to the long‐term treatment of other chronic diseases, such as hypertension, than that used for acute diseases like infections. For many smokers at least, a chronic, prolonged treatment is probably necessary and should include the encouragement to make repeated quit attempts accompanied with multiple treatment episodes over many years. To date, only one study has thoroughly investigated the effect of prolonged treatment on health outcomes. The results in terms of reducing smoking and morbidity have been encouraging

2011: Providing accurate safety information may increase a smoker’s willingness to use nicotine replacement therapy as part of a quit attempt (PDF 4 pages)

  • 93% of smokers did not know that smoking while wearing the nicotine patch does not cause heart attacks; 76% that nicotine gum/lozenge are not as addictive as cigarettes; and 69% that NRT products are not as dangerous as cigarettes. 
  • Over half of the smokers with misperceptions reported that they would be more likely to use NRT (nicotine replacement therapy) to help them quit smoking if they were exposed to information correcting their concerns

Section 5: Nicotine Therapeutic / Medicinal

ADD / ADHD

2006: Effects of transdermal nicotine on attention in adult non-smokers with and without attentional deficits (PDF 11 pages)

  • The results showed nicotine-induced improvement on some measures of sustained attention in the low attention group and some decrement in working memory in the high attention group, which suggests that nicotine tends to optimize rather than improve performance on cognitive tasks.

2008: Acute nicotine improves cognitive deficits in young adults with attention-deficit/hyperactivity disorder (PDF 11 pages)

  • Non-smoking young adults with ADHD-C showed improvements in cognitive performance following nicotine administration in several domains that are central to ADHD.

Addiction

2012: Determinants of Tobacco Use and  Renaming the FTND to the Fagerström Test for Cigarette Dependence (PDF 4 pages)

  • More recently, it has been found that, although nicotine is the most important addictive component of tobacco smoke, it is probably not the only substance involved in the development of tobacco dependence. In light of what is now known about what determines cigarette smoking, it seems timely to propose a renaming of the Fagerstrom Test for Nicotine Dependence (FTND) to the Fagerstrom Test for Cigarette Dependence (FTCD).

2013: Modifications To Labeling of Nicotine Replacement Therapy Products for Over-the-Counter Human Use (PDF 4 pages)

  • We also note that although any nicotine-containing product has the potential to be addicting, based on the available evidence, currently marketed OTC NRT products do not appear to have significant potential for abuse or dependence. A 2010 review of historical reports made to the Agency’s Adverse Event Reporting System and to the Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network between 1984 and 2009 suggested that NRT products have a low potential for abuse. Several published studies have also found that the abuse liability and dependence potential of NRT products is low, especially compared to cigarettes

Alzheimer / Dementia / MCI 

1989: The effects of nicotine on attention, information processing, and short-term memory in patients with dementia of the Alzheimer type  (PDF 5 pages)

  • Nicotine in patients with dementia of the Alzheimer type (DAT) produced a significant and marked improvement in discriminative sensitivity and reaction times on a computerised test of attention and information processing. Nicotine also improved the ability of DAT patients to detect a flickering light in a critical flicker fusion test. These results suggest that nicotine may be acting on cortical mechanisms involved in visual perception and attention, and support the hypothesis that acetylcholine transmission modulates vigilance and discrimination. Nicotine may therefore be of some value in treating deficits in attention and information processing in DAT patients. 

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

1992: Effects of acute subcutaneous nicotine on attention, information processing and short-term memory in Alzheimer’s disease (PDF 10 pages)

  • Nicotine significantly improved sustained visual attention (in both RVIP and DRMLO tasks), reaction time (in both FT and RVIP tasks), and perception (CFF task–both ascending and descending thresholds). 

1996: Does nicotine have beneficial effects in the treatment of certain diseases? (PDF 8 pages)

  • Contrary to popular belief, tobacco smoking may protect against certain diseases. Nicotine is believed to be the pharmacological ingredient responsible for this protective effect.
  • In addition, nicotine may have therapeutic uses in the treatment of Alzheimer’s disease, ulcerative colitis, Gilles de la Tourette’s syndrome and Parkinson’s disease.
  • Drug companies have often refused to fund legitimate and valid research into the potential therapeutic use of nicotine owing to its association with smoking and its image of an abusable drug.
  • Many in the health profession fail to acknowledge the evidence which suggests that nicotine may have potential therapeutic value.

2002: Nicotinic receptors in aging and dementia (PDF 15 pages)

  • Nicotine and nicotinic agonists have been shown to improve cognitive function in aged or impaired subjects.
  • Acute nicotine administration can improve perfor-mance of patients with AD on cognitive tasks, includ-ing verbal learning and memory, attention in a con-tinuous performance task, and accuracy in a visual attention task.
  • In addition to its ability to reverse cognitive deficits following aging, nicotine has been shown to protect against neurotoxic insult in vitro and in vivo. This suggests that nicotine has a dual effect on brain function following aging or injury, such that it can rescue function of remaining neurons, as well as saving neurons that might otherwise undergo cell death.

2010: Nicotine’s effect on neural and cognitive functioning in an aging population (PDF 11 pages)

  • Recent advances in nicotine research have pointed to a number of cognitive and neurological benefits that have been linked to the ingestion of nicotine.
  • This article examines cognitive decline in the elderly and looks at nicotine’s potential role in ameliorating this decline.
  • Nicotine’s effects on cognitive functioning have shown it to increase perception, visual attention,and arousal as well as improving the speed and accu-racy of motor functioning while decreasing reaction time and inhibiting declines in efficiency. In addi-tion, research has shown nicotine to improve long-term and short-term memory, and to increase the ability to withhold inappropriate responses.
  • Research has revealed that chronic exposure to nicotine produces an unusual up-regulation of the nicotinic receptor sites. This increase in receptor sites is thought to provide some protection against neuro-degenerativedisorders such as Alzheimer’s disease.

2012: Nicotine treatment of mild cognitive impairment (MCI) A 6-month double-blind pilot clinical trial (PDF 11 pages)

  • The secondary outcome measures showed significant nicotine-associated improvements in attention, memory, and psychomotor speed, and improvements were seen in patient/informant ratings of cognitive impairment. 
  • Safety and tolerability for transdermal nicotine were excellent. 

2013: Nicotine Prevents Synaptic Impairment Induced by Amyloid-β Oligomers Through α7-Nicotinic Acetylcholine Receptor Activation (PDF 21 pages) **Animal Study**

  • Taken together, these results demonstrate that nicotine prevents memory deficits and synaptic impairment induced by Aβ oligomers. In addition, nicotine improves memory in young APP/PS1 transgenic mice before extensive amyloid deposition and senile plaque development, and also in old mice where senile plaques have already formed.

Aphthous ulcers

1991: Recurrent aphthous ulcers and nicotine (PDF 2 pages)

  • The aim of this study was to investigate the effect of nicotine, in the form of Nicorette tablets, on aphthous ulcers in non-smoking patients. This preliminary trial shows that nicotine may have a beneficial effect on aphthous ulcers.

Arthritis

Osteo

Rheumatoid 

Auditory

2019: Nicotine enhances auditory processing in healthy and normal-hearing young adult 

nonsmokers. (PDF 8 pages)

  • Nicotine improves auditory performance in difficult listening situations. The present results support future investigation of nicotine effects in clinical populations with auditory processing deficits or reduced cholinergic activation.

Autism

2018:An Exploratory Trial of Transdermal Nicotine for Aggression and Irritability in Adults with Autism Spectrum Disorder (PDF 16 pages)

  • Taken together, our study provides evidence for the feasibility and tolerability of transdermal nicotine (TN/TNP) in a small sample of adults with severe Autism Spectrum Disorder (ASD) symptoms and pathological chronic aggression and irritability. 
  • Our results also suggest that TN may have a beneficial effect on aggression, irritability, and sleep in ASD, though the sample size of this study is too small to make definitive conclusions. 

Behcet’s disease

2000: Nicotine Patches for Aphthous Ulcers Due to Behçet’s Syndrome (PDF 1 page)

  • We describe a woman with Behçet’s syndrome characterized by recurrent oral and genital aphthous ulcers, severe eye involvement, and the onset of arthritis at the age of 29 years. At the age of 35 several large and extremely painful buccal aphthous ulcers developed. Therapy with a nicotine patch led to a regression of all aphthous ulcers within a few days. A month later, after the patient had stopped using the nicotine patches, four aphthous ulcers developed within a week. These ulcers rapidly regressed once she resumed using the nicotine patches.

2010: Nicotine-patch therapy on mucocutaneous lesions of Behçet’s disease: a case series (PDF 4 pages)

  • In this report, we describe five ex-smoker BD patients with active mucocutaneous lesions, not responsive to standard pharmacological treatments and treated with transdermal nicotine patches. Four out of five patients quickly responded to nicotine-patch therapy and experienced a complete regression of all mucocutaneous lesions within 6 months of observation.

Brain Injury

2004: Nicotinic receptor modulation for neuroprotection and enhancement of functional recovery following brain injury or disease (PDF 19 pages)

  • Several studies have shown that nicotine treatment can attenuate cognitive deficits produced by medial septal lesions, lesions of the nucleus basalis, and traumatic brain injury.

Cancer / Cancer Treatments

2013: Nicotine is a pain reliever in trauma- and chemotherapy-induced neuropathy models (PDF 8 pages)- Dual listed under Nicotine / Cancer and Nicotine / Pain

  • Nicotine significantly reduced antiviral-dependent alterations of the nociceptive threshold. 
  • Moreover, nicotine decreased neuropathic pain induced by repeated intraperitoneal administration of the anticancer agent oxaliplatin (2.4 mg/kg), lowering the hypersensitivity to mechanical and thermal stimuli. 
  • In conclusion, intraperitoneal nicotine administration controls neuropathic pain evoked by traumatic or toxic nervous system alterations. These results support the nAChR modulation as a possible therapeutic approach to the complex, undertreated chemotherapy-induced neuropathies. 

2020: Nicotine inhibits MAPK signaling and spheroid invasion in ovarian cancer cells (Must pay to view PDF) 

  • Nicotine inhibits ovarian cancer cell ERK and p38 MAPK signaling.
  • Nicotine inhibits ovarian cancer proliferation and spheroid invasion.

Cannabis / THC

2020: Nicotine patch for cannabis withdrawal symptom relief: a randomized controlled trial (PDF 13 pages)

  • The findings provide the first evidence that NP (Nicotine Patch) may be able to attenuate NA (negative affect) – related withdrawal symptoms in individuals with cannabis use disorder who are not heavy users of tobacco or nicotine.

Cognitive / IQ

1992: Nicotine as a cognitive enhancer  (PDF 11pages)

  • Nicotine improves attention in a wide variety of tasks in healthy volunteers. 
  • Nicotine improves immediate and longer term memory in healthy volunteers. 
  • Nicotine improves attention in patients with probable Alzheimer’s Disease. 
  • While some of the memory effects of nicotine may be due to enhanced attention, others seem to be the result of improved consolidation as shown by post-trial dosing. 

1994: Smoking and Raven IQ (PDF 3 pages)

  • Nicotine has recently been shown to enhance measures of information processing speed including the decision time (DT) component of simple and choice reaction time and the string length measure of evoked potential waveform complexity. Both (DT and string length) have been previously demonstrated to correlate with performance on standard intelligence tests (IQ).
  • In this experiment we used the Raven Advanced Progressive Matrices (APM) test. APM scores were significantly higher in the smoking session compared to the non-smoking session, suggesting that nicotine acts to enhance physiological processes underlying performance on intellectual tasks.

2003: Psychoactive Drugs and Pilot Performance: A Comparison of Nicotine, Donepezil, and Alcohol Effects (PDF 8 pages)

  • Compared to placebo, nicotine and donepezil significantly improved, while alcohol significantly impaired overall flight performance.
  • Both cholinergic drugs showed the largest effects on flight tasks requiring sustained visual attention.

2018: Cognitive Effects of Nicotine: Recent Progress (PDF 12 pages)

  • Preclinical models and human studies have demonstrated that nicotine has cognitive-enhancing effects. Attention, working memory, fine motor skills and episodic memory functions are particularly sensitive to nicotine’s effects. 

2020: Effects of Nicotine on Task Switching and Distraction in Non-smokers. An fMRI Study (PDF 11 pages)

  • Nicotine improves sustained attention and reduces distractor interference, promoting cognitive stability.
  • Nicotine enhances response times without differential impact on task switching or distraction.

Digestive Tract / Bowel

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

1996: Does nicotine have beneficial effects in the treatment of certain diseases? (PDF 8 pages)

  • Contrary to popular belief, tobacco smoking may protect against certain diseases. Nicotine is believed to be the pharmacological ingredient responsible for this protective effect.
  • In addition, nicotine may have therapeutic uses in the treatment of Alzheimer’s disease, ulcerative colitis, Gilles de la Tourette’s syndrome and Parkinson’s disease.
  • Drug companies have often refused to fund legitimate and valid research into the potential therapeutic use of nicotine owing to its association with smoking and its image of an abusable drug.
  • Many in the health profession fail to acknowledge the evidence which suggests that nicotine may have potential therapeutic value.

1996: The role of cigarettes and nicotine in the onset and treatment of ulcerative colitis. (PDF 6 pages)

  • Nicotine is believed to be the pharmacological ingredient of tobacco that is responsible for this beneficial deterrent of UC and several clinical trials using nicotine have demonstrated it to be an effective therapeutic agent in the treatment of ulcerative colitis. Although the aetiology of ulcerative colitis is unclear, current research using nicotine-based products has produced some interesting clues, together with the possibility of some form of therapeutic treatment based on nicotine administration.

1999: Nicotine treatment for ulcerative colitis (PDF 4 pages)

  • No withdrawal symptoms suggesting nicotine addiction have been reported either after 4–6 weeks of therapy in short-term studies, or after a period of up to 6 months in the only long-term study available
  • It can be concluded from these data that transdermal nicotine alone has limited efficacy in active ulcerative colitis and is ineffective as maintenance treatment. On the other hand, if administered in combination with mesalazine, nicotine is superior to placebo in promoting clinical remission of ulcerative colitis of mild to moderate degree, may represent an efficacious alternative to steroids in selected cases and, when effective, seems to exert a longer-lasting therapeutic effect than prednisone.

2004: Transdermal nicotine for induction of remission in ulcerative colitis (PDF 23 pages)

  • Ulcerative colitis is largely a disease of nonsmokers and patients who have quit smoking. Randomised controlled trials were therefore developed to test the hypothesis that nicotine patches can induce remission of a flare of ulcerative colitis. This review provides evidence that transdermal nicotine is superior to placebo (fake patch) for the treatment of active ulcerative colitis.

2008: Nicotine Enemas for Active Crohn’s Colitis: An Open Pilot Study (PDF 7 pages)

  • Smoking has a detrimental effect in Crohn’s disease (CD), but this may be due to factors in smoking other than nicotine. Given that transdermal nicotine benefits ulcerative colitis (UC), and there is a considerable overlap in the treatment of UC and CD, the possible beneficial effect of nicotine has been examined in patients with Crohn’s colitis.
  • In this relatively small study of patients with active Crohn’s colitis, 6 mg nicotine enemas appeared to be of clinical benefit in most patients. They were well tolerated and safe.

Downs Syndrome 

2000: Effects of transdermal nicotine on cognitive performance in Down’s syndrome (PDF 2 pages)

  • We investigated the effect of nicotine-agonistic stimulation with 5 mg transdermal patches, compared with placebo, on cognitive performance in five adults with the disorder. Improvements possibly related to attention and information processing were seen for Down’s syndrome patients compared with healthy controls. Our preliminary findings are encouraging, although not generalizable because of small numbers. 

Endurance / Exercise / Athletic Performance

2006: Effect of transdermal nicotine administration on exercise endurance in men (PDF 9 pages)

  • In summary, the results presented here clearly demonstrate that nicotine improved exercise endurance by 17 ± 7%, and in the absence of any effect on the usual peripheral markers, such as ventilation, heart rate and blood metabolites, we conclude that nicotine prolongs endurance by a central mechanism that may involve nicotinic receptor activation and/or altered activity of dopaminergic pathways.

HIV/AIDS

Mental Health

Anxiety

Behavior Issues

2020: Regulation of aggressive behaviors by nicotinic acetylcholine receptors: Animal models, human genetics, and clinical studies (PDF 10 pages)

  • Small clinical trials and case series report anti-aggressive effects of nicotine.

Depression

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

1996: Antidepressant effect of transdermal nicotine patches in nonsmoking patients with major depression (No link to PDF found)

  • A high frequency of cigarette smoking has been reported among individuals with major depression.
  • Results of the visual analog scale and HAM-D showed a significant improvement in depression after the second day of nicotine patches.

1998: A novel effect of nicotine on mood and sleep in major depression (PDF 4 pages)

  • These findings suggest that nicotine receptor activation may be important in major depression and shows for the first time that nicotine patches may be useful in the treatment of depression. 

1999: Antidepressant effects of nicotine in an animal model of depression (PDF 7 pages) **Animal Study**

  • Epidemiological studies indicate a high incidence of cigarette smoking among depressed individuals. Moreover, individuals with a history of depression have a much harder time giving up smoking. It has been postulated that smoking may reflect an attempt at self-medication with nicotine by these individuals.
  • The data strongly implicate the involvement of central nicotinic receptors in the depressive characteristics of the FSL rats, and suggest that nicotinic agonists may have therapeutic benefits in depressive disorders. 

2002: Relationship between mood improvement and sleep changes with acute nicotine administration in non-smoking major depressed patients (No link to PDF found)

  • Acute administration of nicotine patches produced rapid eye movement sleep (REM) increases in non-smoking major depressed patients as well as clinical improvement in mood. Antidepressant effect was also observed after four continuous days of nicotine administration.

2017: Nicotine and Networks: Potential for Enhancement of Mood and Cognition in Late-Life Depression (PDF 26 pages)

  • Late-life depression (LLD) is characterized by both lower mood and poor cognitive performance, symptoms that often do not fully respond to current antidepressant medications.
  • Both preclinical and clinical studies support that nicotine and other nAChR agonists can improve depressive behavior, mood, and cognitive performance. nAChR agonists also demonstrate neuropharmacologic effects that oppose the intrinsic network alterations reported in MDD (major depressive disorder). Through modulation of intrinsic functional networks, nAChR agonists may reduce depressive symptoms, enhance emotional regulation ability, and improve cognitive deficits common in LLD. For these reasons, we propose nAChR agonists as a potential novel treatment for the mood and cognitive symptoms of LLD.

2018: Transdermal Nicotine for the Treatment of Mood and Cognitive Symptoms in Non-Smokers with Late-Life Depression (PDF 17 pages)

  • Late Life Depression (LLD) is characterized by poor antidepressant response and cognitive dysfunction. Late life depression has no currently approved treatment that improves both its mood and cognitive symptoms.
  • We observed robust response (86.7%) and remission rates (53.3%). There was a significant decrease in MADRS (Montgomery-Asberg Depression Rating scale) over the study, with improvement seen as early as three weeks. We also observed improvement in apathy and rumination. We did not observe improvement on the CPT (Conners Continuous Performance Test), but did observe improvement in subjective cognitive performance and signals of potential drug effects on secondary cognitive measures of working memory, episodic memory, and self-referential emotional processing.

2018: Nicotine normalizes cortico-striatal connectivity in non-smoking individuals with major depressive disorder (MDD)  (PDF 7 pages)

  • In MDD, acute nicotine administration normalized both pathways to the level of healthy controls, while having no impact on healthy controls.
  • These results indicate that nicotine normalizes dysfunctional cortico-striatal communication in unmedicated non-smokers with MDD.

Schizophrenia 

2009: Exogenous nicotine normalises sensory gating in schizophrenia; therapeutic implications (PDF 4 pages)

  • This is the principal reason for the markedly increased rate of cigarette smoking in people with schizophrenia: tobacco cigarette smoking represents an attempt at self-medication in schizophrenia, because the additional nicotine so provided alleviates the hypofunctional sensory gating seen in this illness.

2020: The effects of acute nicotine administration on cognitive and early sensory processes in schizophrenia: a systematic review (PDF 13 pages)

  • Cognitive and early sensory alterations are core features of schizophrenia. A single dose of nicotine can improve those features in patients. Attention domain is the most responsive to nicotine in patients. Effects vary upon type of neuropsychological assessment and nicotine intake condition.

Movement Disorders (not diagnosis specific)

2014: Role for the nicotinic cholinergic system in movement disorders; therapeutic implications (PDF 24 pages) (animal studies)

  • Several nAChR subtypes appear to be involved in these beneficial effects of nicotine and nAChR drugs including α4β2*, α6β2* and α7 nAChRs (the asterisk indicates the possible presence of other subunits in the receptor). Overall, the above findings, coupled with nicotine’s neuroprotective effects, suggest that nAChR drugs have potential for future drug development for movement disorders.

Multiple Sclerosis – Humans / Experimental Autoimmune Encephalomyelitis (EAE) – Animal Studies

2013: Novel Therapeutic Approach by Nicotine in Experimental Model of Multiple Sclerosis (PDF 6 pages) **Animal Study**

  • Due to the proven therapeutic effect of nicotine on AD (Alzheimer’s Disease) and PD (Parkinson’s Disease), we decided to study the role of nicotine in EAE as an animal model of MS. Our treatment group showed less inflammation in histopathological evaluation along with myelin sheet protection. Moreover, prevention group showed less inflammation compared with treatment group. Thus, nicotine might be recommended as a promising drug for MS therapy.

2014:The Experimental Autoimmune Encephalomyelitis Disease Course Is Modulated by Nicotine and Other Cigarette Smoke Components (PDF 14 pages) **Animal Study**

  • Epidemiological studies have reported that cigarette smoking increases the risk of developing multiple sclerosis (MS) and accelerates its progression.
  • Our results show that nicotine reduces the severity of EAE, as shown by reduced demyelination, increased body weight, and attenuated microglial activation. Nicotine 

administration after the development of EAE symptoms prevented further disease exacerbation, suggesting that it might be useful as an EAE/MS therapeutic. In contrast, the remaining components of cigarette smoke, delivered as cigarette smoke condensate (CSC), accelerated and increased adverse clinical symptoms during the early stages of EAE.

2016: Study: Infiltration of CCR2+Ly6Chigh Proinflammatory Monocytes and Neutrophils into the Central Nervous System Is Modulated by Nicotinic Acetylcholine Receptors in a Model of Multiple Sclerosis (PDF 14 pages) **Animal Study**

 This study provides evidence that nicotine alters the infiltration of proinflammatory monocytes and neutrophils into the CNS of EAE mice via multiple nAChRs, including the α7 and α9 subtypes. Nicotine appears to achieve these effects by inhibiting the expression of CCL2 and CXCL2, two cytokines involved in the chemotaxis of proinflammatory monocytes and neutrophils, respectively. The use of ligands that are selective for one or both of these nAChR subtypes may offer a beneficial clinical outcome, and thus provide a valuable therapeutic strategy for neuroinflammatory disorders such as MS.

Article: MS Society-funded study shows that nicotine reduces the invasion of harmful immune cells into the brain in mice with an MS-like disease 

  • From the Article: Nicotine is an ingredient of tobacco products such as cigarettes, which are considered a major risk factor for MS. The nicotine used in this study was devoid of other chemicals normally found in cigarettes. These observations support the findings of an earlier Swedish study in which cigarette smoking was associated with greater MS risk, but also showed that chewable tobacco was associated with lower risk, suggesting that factors in smoked tobacco other than nicotine may be contributing to MS risk.
  • From the Article: Nicotine, through its activation of nicotinic acetycholine receptors, is capable of alleviating disability symptoms in mice with an MS-like disease. This is accomplished, in part, by the drug’s ability to reduce the number of pro-inflammatory monocytes and neutrophils that infiltrate the brain and spinal cord.

OCD (Obsessive Compulsive Disorder)

2020: Efficacy of nicotine administration on obsessions and compulsions in OCD: a systematic review (PDF 11 pages)

  • Nicotine may ameliorate OC symptoms in severe, treatment-refractory OCD patients. Although encouraging, these initial positive effects should be tested in large controlled studies.

Pain 

2008: Transdermal Nicotine for Analgesia After Radical Retropubic Prostatectomy (PDF 6 pages)

  • In conclusion, the preoperative application of a 7 mg nicotine patch resulted in a significant reduction in postoperative opioid consumption in nonsmoking men undergoing RRP in this study.

2011: Randomised trial of intranasal nicotine and postoperative pain, nausea and vomiting in non-smoking women (PDF 7 pages)

  • Intraoperative use of intranasal nicotine has a sustained opioid-sparing effect in non-smoking women undergoing gynaecological procedures and is associated with a higher frequency of nausea. 

2013: Nicotine is a pain reliever in trauma- and chemotherapy-induced neuropathy models (PDF 8 pages) – Dual listed under Nicotine / Cancer and Nicotine / Pain

  • Nicotine significantly reduced antiviral-dependent alterations of the nociceptive threshold. 
  • Moreover, nicotine decreased neuropathic pain induced by repeated intraperitoneal administration of the anticancer agent oxaliplatin (2.4 mg/kg), lowering the hypersensitivity to mechanical and thermal stimuli. 
  • In conclusion, intraperitoneal nicotine administration controls neuropathic pain evoked by traumatic or toxic nervous system alterations. These results support the nAChR modulation as a possible therapeutic approach to the complex, undertreated chemotherapy-induced neuropathies. 

2020: Effectiveness of nicotine patch for the control of pain, oedema, and trismus following third molar surgery: a randomized clinical trial (PDF 11 pages)

  • The positive findings in the present study in surgeries performed under local anaesthesia are in agreement with data from systematic reviews that have reported the effectiveness of nicotine in the control of postoperative pain following surgery under general anaesthesia.
  • This study establishes a new prevention and treatment modality regarding pain, oedema, and trismus in a versatile, convenient, safe, and effective form, thereby minimizing gastrointestinal and cardiovascular disorders caused by the use of anti-inflammatory drugs in third molar surgeries.

Parkinson Disease

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

1996: Does nicotine have beneficial effects in the treatment of certain diseases? (PDF 8 pages)

  • Contrary to popular belief, tobacco smoking may protect against certain diseases. Nicotine is believed to be the pharmacological ingredient responsible for this protective effect.
  • In addition, nicotine may have therapeutic uses in the treatment of Alzheimer’s disease, ulcerative colitis, Gilles de la Tourette’s syndrome and Parkinson’s disease.
  • Drug companies have often refused to fund legitimate and valid research into the potential therapeutic use of nicotine owing to its association with smoking and its image of an abusable drug.
  • Many in the health profession fail to acknowledge the evidence which suggests that nicotine may have potential therapeutic value.

2007: Nicotinic receptors as CNS targets for Parkinson’s disease (PDF 19 pages)

  • This possibility stems from results showing that chronic nicotine treatment improved striatal integrity and function.

2020: Dietary nicotine intake and risk of Parkinson disease: a prospective study (PDF 8 pages)

  • Women with greater dietary nicotine intake had a lower risk of Parkinson Disease (PD) than those with lower intake.

Pregnancy 

2020: Fetal safety of nicotine replacement therapy in pregnancy: systematic review and meta‐analysis (PDF is 51 pages) 

  • Available evidence from randomised controlled trials and non‐randomised comparative studies does not currently provide clear evidence as to whether maternal use of nicotine replacement therapy during pregnancy is harmful to the fetus.

Psoriasis

2012: Can nicotine use alleviate symptoms of psoriasis? (PDF 4 pages)

  • In light of recent data demonstrating that psoriasis is an immune-mediated disease, the possibility that novel anti-inflammatory treatments such as nicotine replacement therapy or analogues could have a beneficial effect on patients with psoriasis should be considered. This case described one such occasion in which it appeared that nicotine had a therapeutic effect on a patient’s psoriasis. 

Pyoderma Gangrenosum

1995: Successful Treatment of Pyoderma Gangrenosum with Nicotine Chewing Gum (Link is PDF 2 pages)

  • We used nicotine chewing gum for the treatment of pyoderma gangrenosum with remarkable results. We strongly suggest that nicotine chewing gum may not only be beneficial in treating pyoderma gangrenosum but may also be useful in treating other skin disorders with prominent neutrophilic infiltrations such as Behcet’s disease, Sweet disease, allergic vasculitis, and recurrent oral aphthae, the last of which is known to respond to smoking.

1998: Nicotine for Pyoderma Gangrenosum (PDF 2 pages)

  • Herein we describe a patient with pyoderma gangrenosum who responded twice to topical nicotine within 4 weeks and 3 months, respectively, without any adverse effects.

2004: Successful treatment of pyoderma gangrenosum with topical 0.5% nicotine cream (PDF 5 pages)

  • Two patients with pyoderma gangrenosum treated with topical nicotine 0.5% w/w cetamacrogol formula A cream are described here, both of whom had dramatic clinical resolution of their pyoderma gangrenosum.

Sarcoidosis

2013: Nicotine Treatment Improves Toll-Like Receptor 2 and Toll-Like Receptor 9 Responsiveness in Active Pulmonary Sarcoidosis (PDF 11 pages)

  • Nicotine treatment in active pulmonary sarcoidosis was well tolerated and restored peripheral immune responsiveness to TLR2 and TLR9 agonists and expansion of FoxP3 + Tregs, including a specific “preactivated” (CD25 ) phenotype. 
  • The immune phenotype of patients with symptomatic sarcoidosis treated with nicotine closely resembled that of asymptomatic patients, supporting the notion that nicotine treatment may be beneficial in this patient population. 

Seizures / Epilepsy

2003: Nicotine as an Antiepileptic Agent in ADNFLE: An N‐of‐One Study (PDF 3 pages)  

  • In this individual with refractory ADNFLE, nicotine had a therapeutic effect on seizures, and it may be useful to others with this disorder. 

2012: Resolution of epileptic encephalopathy following treatment with transdermal nicotine (PDF 3 pages)   

  • We report resolution of an epileptic encephalopathy by administration of transdermal nicotine patches in an adolescent with severe nonlesional refractory frontal lobe epilepsy. The 18.5‐year‐old female patient had refractory epilepsy from the age of 11. Recurrent electroencephalography (EEG) recordings showed mostly generalized activity, albeit with right frontal predominance. Almost all antiepileptic medications failed to provide benefit. She developed an encephalopathic state with cognitive decline. The nonlesional frontal lobe epilepsy and a family history of a cousin with nocturnal epilepsy with frontal origin suggested genetic etiology. Transdermal nicotine patches brought complete resolution of the seizures, normalization of the EEG, and a significant improvement in her thinking process and speech organization. Sequencing of the CHRNB2 and CHRNA4 genes did not detect a mutation. Transdermal nicotine patches should be considered in severe pharmacoresistant frontal lobe epilepsy.

2014: News: Nicotine patch stops child’s seizures

2015: Transdermal Nicotine Patch as a Novel Treatment for Epilepsy Associated with a Mutation in the Nicotinic Acetylcholine Receptor (S35.002) 

2020: Remarkable effect of transdermal nicotine in children with CHRNA4-related autosomal dominant sleep-related hypermotor epilepsy

2020: Nicotine: A Targeted Therapy for Epilepsy Due to nAChR Gene Variants

Sleep Apnea 

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

Spinal Cord Injury

2008: Nicotine attenuates iNOS expression and contributes to neuroprotection in a compressive model of spinal cord injury (PDF 11 pages) **Animal Study**

  • Primary impact to the spinal cord results in stimulation of secondary processes that potentiate the initial trauma.Recent evidence indicates that nicotine can exert potent antioxidant and neuroprotective effects in spinal cord injury (SCI). 
  • In conclusion, the results of the present study indicate that iNOS is induced in the early stages of SCI, leading to increased nitration of protein tyrosine residues and potentiation of inflammatory responses. Microglial cells appear to be the main cellular source of iNOS in SCI. In addition, nicotine-induced anti-inflammatory effects in SCI are mediated, at least in part, by the attenuation of iNOS overexpression through the receptor-mediated mechanism. This data may have significant therapeutic implications for the targeting of nicotine receptors in the treatment of compressive spinal cord trauma.

Tourette Syndrome

1989: Nicotine and cannabinoids as adjuncts to neuroleptics in the treatment of tourette syndrome and other motor disorders (PDF 5 pages)

  • Animal studies suggest nicotine and cannabinoids may significantly enhance the therapeutic value of neuroleptics in motor disorders. This was recently demonstrated in humans by the finding that chewing nicotine gum produced striking relief from tics and other symptoms of Tourette syndrome not controlled by neuroleptic treatment alone. It appears that the use of nicotine or cannabinoids may greatly improve the clinical response to neuroleptics in motor disorders.

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

1992: The effects of nicotine plus haloperidol compared to nicotine only and placebo nicotine only in reducing tic severity and frequency in Tourette’s disorder (TD) (PDF 9 pages)

  • In this study, nicotine markedly potentiated haloperidol effects in treating TD, and showed lesser effects on TD when used alone.

1996: Case study: long-term potentiation of neuroleptics with transdermal nicotine in Tourette’s syndrome  (PDF 6 pages)

  • Sixteen Tourette’s syndrome patients, aged 9 to 15 years, whose symptoms were not controlled with neuroleptics, were followed for various lengths of time after the application of one 7 mg transdermal nicotine patch (TNP) for 24 hours. While there was a broad range in individual response, application of the TNP produced significant reductions in Yale Global Tic Severity Scale scores relative to baseline, with an average duration of effect lasting between 1 and 2 weeks. Side effects, for the most part, were transient.
  • One of the 16 patients did not require a secondTNP. 1 patient received a 2nd TNP, but moved out of state before a follow up evaluation could be made.
  • Eleven of the 14 patients had greater percentage changes after the second TNP than after the first TNP, while 6 had no change and only1 patient had less percentage change.

1996: Does nicotine have beneficial effects in the treatment of certain diseases? (PDF 8 pages)

  • Contrary to popular belief, tobacco smoking may protect against certain diseases. Nicotine is believed to be the pharmacological ingredient responsible for this protective effect.
  • In addition, nicotine may have therapeutic uses in the treatment of Alzheimer’s disease, ulcerative colitis, Gilles de la Tourette’s syndrome and Parkinson’s disease.
  • Drug companies have often refused to fund legitimate and valid research into the potential therapeutic use of nicotine owing to its association with smoking and its image of an abusable drug.
  • Many in the health profession fail to acknowledge the evidence which suggests that nicotine may have potential therapeutic value.

1997: Nicotine for the treatment of Tourette’s syndrome (link is for the PDF – 5 pages)

  • In combination with neuroleptic therapy, nicotine gum reduces both the frequency and severity of TS symptoms, but the side effects produced by this form of administration often limit compliance. 
  • Within 24 hr of the application of a single 7-mg TNP (nicotine patch), the severity and frequency of tic symptoms is significantly decreased over baseline. This response is rapid, often reaching its maximum in the first 3 hr after application of a single patch. The duration of therapeutic effect of a single 7-mg TNP is variable and may last for about l-2 weeks. 
  • Application of a 7-mg TNP to children and adolescents with TS appears to be clinically safe, with transient side effects. However, no child under 8 years of age and weighing less than 25 kg was considered for TNP treatment. 

2001: Transdermal nicotine and haloperidol in Tourette’s disorder: a double-blind placebo-controlled study (no link to PDF found)

  • Transdermal nicotine was superior to placebo in reducing behavioral symptoms when patients were receiving an optimal dose of haloperidol, when the dose of haloperidol was reduced by 50%, and when the patch had been discontinued for 2 weeks. These findings confirm earlier open-label findings and suggest that combining nicotinic receptor modulation and neuroleptics could be a therapeutic option for the treatment of Tourette’s disorder.

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Weight Loss / Appetite Control / Metabolism / Obesity

1991: Beneficial effects of nicotine (PDF 6 pages)

  • When chronically taken, nicotine may result in: (1) positive reinforcement, (2) negative reinforcement (mood normalization), (3) reduction of body weight, (4) enhancement of performance, and protection against; (5) Parkinson’s disease (6) Tourette’s disease (7) Alzheimer’s disease, (8) ulcerative colitis and (9) sleep apnea. 

Section 6: Nicotine – COVID / SARS / ARDS

Nicotine Replacement Therapy (NRT)

2020: Nicotine-replacement therapy, as a surrogate of smoking, and the risk of hospitalization with Covid-19 and all-cause mortality: a nationwide, observational cohort study in France (PDF 40 pages)

  • From February 15, 2020 to June 7, 2020, hospitalization with Covid-19 occurred in 647 patients (151 patients in the nicotine-replacement therapy group and 496 patients in the unexposed group).
  • Results In the first analysis, 297,070 individuals without major smoking-related diseases exposed to nicotine-replacement therapy were matched with 558,228 unexposed individuals without major smoking-related diseases.
    • In the main multivariable analysis, nicotine-replacement therapy was associated with a decreased risk of hospitalization with Covid-19 compared with unexposed individuals.
    • Nicotine-replacement therapy exposure was also associated with a decreased risk of intubation or death in hospitalized individuals with Covid-19. (13 vs. 73 patients).

Smoking

2020: How nicotine can inhibit cytokine storm in the lungs and prevent or lessen the severity of COVID-19 infection? (PDF 2 pages) 

  • COVID-19 positive patients who smoke are more often asymptomatic or exhibit less severe respiratory symptoms than non-smokers.
  • The macrophages, which are directly infected by the SARS-CoV-2 virus, may drive the cytokine storm in the lings.
  • Stimulation of macrophage ACh receptors by nicotine inhibits pro-inflammatory cytokines production and inflammatory response.
  • The nicotine use may lessen or eliminate ARDS in the smoking COVID -19 patients.

2020: Characteristics and risk factors for COVID-19 diagnosis and adverse outcomes in Mexico: an analysis of 89,756 laboratory–confirmed COVID-19 cases (PDF 30 pages)

  • COVID-19 patients were disproportionately older, males and with increased prevalence of one or more comorbidities, particularly diabetes, obesity, and hypertension.
  • Current smokers were 23% less likely to be diagnosed with COVID-19 compared to non-smokers.

Smokeless Tobacco

Vapor Technology

Section 7: Misc. / Not Categorized

Letters, publications, articles (not studies) Resource List 

Section 8: Quitting Smoking/Relapse Prevention (No THR)

Relapse 

2005: Relapse prevention interventions for smoking cessation. 

(must pay to view full study) 

  • At the moment there is insufficient evidence to support the use of any specific intervention for helping smokers who have successfully quit for a short time to avoid relapse. The verdict is strongest for interventions focusing on identifying and resolving tempting situations, as most studies were concerned with these. There is very little research available regarding other approaches. Until more evidence becomes available it may be more efficient to focus resources on supporting the initial cessation attempt rather than on additional relapse prevention efforts

2009: Relapse prevention interventions for smoking cessation. (Update from 2005)

(must pay to view full study) 

  • At the moment there is insufficient evidence to support the use of any specific behavioural intervention for helping smokers who have successfully quit for a short time to avoid relapse. The verdict is strongest for interventions focusing on identifying and resolving tempting situations, as most studies were concerned with these. There is little research available regarding other behavioural approaches. Extended treatment with varenicline may prevent relapse. Extended treatment with bupropion is unlikely to have a clinically important effect. Studies of extended treatment with nicotine replacement are needed.

2013: Relapse prevention interventions for smoking cessation. (Update from 2009)

(must pay to view full study) 

  • At the moment, there is insufficient evidence to support the use of any specific behavioural intervention to help smokers who have successfully quit for a short time to avoid relapse. The verdict is strongest for interventions focused on identifying and resolving tempting situations, as most studies were concerned with these. Little research is available regarding other behavioural approaches.Extended treatment with varenicline may prevent relapse. Extended treatment with bupropion is unlikely to have a clinically important effect. Studies of extended treatment with nicotine replacement are needed.

2018 Article: Ex-smokers crave lost identity, study shows 

(must pay to see study) 

  • Ex-smokers may not be able to resist lighting up again in order to recover a sense of ‘who they are’. New findings suggest that smokers who have quit often relapse because they want to recapture a sense of lost social identity. And that many ex-smokers experience quitting as a ‘loss’.

2019: Relapse prevention interventions for smoking cessation. (Update from 2013)

(must pay to view full study) 

  • Behavioural interventions that teach people to recognise situations that are high risk for relapse along with strategies to cope with them provided no worthwhile benefit in preventing relapse in assisted abstainers, although unexplained statistical heterogeneity means we are only moderately certain of this. In people who have successfully quit smoking using pharmacotherapy, there were mixed results regarding extending pharmacotherapy for longer than is standard. Extended treatment with varenicline helped to prevent relapse; evidence for the effect estimate was of moderate certainty, limited by unexplained statistical heterogeneity. Moderate-certainty evidence, limited by imprecision, did not detect a benefit from extended treatment with bupropion, though confidence intervals mean we could not rule out a clinically important benefit at this stage. Low-certainty evidence, limited by imprecision, did not show a benefit of extended treatment with nicotine replacement therapy in preventing relapse in assisted abstainers. More research is needed in this area, especially as the evidence for extended nicotine replacement therapy in unassisted abstainers did suggest a benefit.

Section 9: Other inhaled uses of e-liquid ingredients (not NRT) 

2002: Formulations and Nebulizer Performance 

  • To deliver a drug by nebulization, the drug must first be dispersed in a liquid (usually aqueous) medium. After application of a dispersing force (either a jet of gas or ultrasonic waves), the drug particles are contained within the aerosol droplets, which are then inhaled. Some drugs readily dissolve in water, whereas others need a cosolvent such as ethanol or propylene glycol.

Section 10: EVALI (note VEA = vitamin E acetate)

2019: Vaping and lung disease in the US: PHE’s advice

  • Dr Dana Meaney-Delman, head of the CDC team investigating the outbreak has reported that “We’ve narrowed this clearly to THC-containing products that are associated with most patients who are experiencing lung injury. The specific substance or substances we have not identified yet”.
  • We need to be clear about what this outbreak is and is not. It is not a problem linked to long-term use of regulated nicotine vaping products. If it were, we would expect to see a very different demographic profile affected, more typical of long term vapers.
  • PHE has not changed its advice on nicotine containing e-cigarettes: Smokers should consider switching completely and vapers should stop smoking.
  • The evidence still shows that vaping carries a small fraction of the risk of smoking. Using a nicotine-containing e-cigarette makes it much more likely someone will quit successfully than relying on willpower alone. But it’s important to use regulated e-liquids and never risk vaping home-made or illicit e-liquids or adding substances.

2020: Sparking the Discussion about Vaping and Anesthesia: Comment 

  • The authors refer to an outbreak of 53 cases of e-cigarette and vaping–related lung injury, in which 84% of the cases admitted to the use of tetrahydrocannabinol products. The remaining 16% may have concealed the use of an illegal product, or not known what they were using. In those cases of e-cigarette and vaping–related lung injury where bronchoalveolar lavage was performed, 100% of the specimens were positive for vitamin E acetate, a dangerous contaminant in tetrahydrocannabinol oil.  This outbreak is troubling but it is unrelated to the use of legal nicotine-based vaping products.

2020: Analysis of Cannabinoid-Containing Fluids in Illicit Vaping Cartridges Recovered from Pulmonary Injury Patients: Identification of Vitamin E Acetate as a Major Diluent (PDF 19 pages)

  • As of December 12, 2019, the Wadsworth Center has analyzed 206 vaporizer fluids from 61 NYS EVALI cases. Of these, 147 contained THC, and 59 contained nicotine. Of the 147 THC-containing fluids, 101 (69%) contained VEA. In the nicotine-containing products we analyzed, we detected no unusual compounds that appeared to be of concern.
  • There is additional evidence of a strong association of VEA with EVALI. In the initial analyses of bronchoalveolar lavage fluids from EVALI patients, 28 of 28 fluids contained vitamin E acetate.

2020: Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI (PDF 9 pages)

  • The FDA detected no vitamin E acetate in 197 case-associated nicotine products analyzed to date. The viscosity of vitamin E acetate makes it undesirable as an additive to nicotine solutions.
  • Data that have been reported to date indicate that vitamin E acetate in the supply of THC-containing products and use among patients with EVALI aligns with the timing of the 2019 EVALI outbreak. In Minnesota, 10 of 10 products seized by law enforcement during 2018, before the EVALI outbreak, did not contain vitamin E acetate, whereas 20 of 20 THC-containing products seized by law enforcement during September 2019, at the peak of the outbreak, contained vitamin E acetate.
  • Pure THC oil has a viscosity like that of vitamin E acetate. Cutting THC oil with vitamin E acetate has been reported to be common in the illicit market.

2020: NEWS THAT TAKES YOUR BREATH AWAY: RISK PERCEPTIONS DURING AN OUTBREAK OF VAPING-RELATED LUNG INJURIES (Link is to PDF – 30 pages)

  • The  early  versions  of  the  CDC  EVALI  recommendations  were  also  consistent  with the precautionary  principle;  the  early  recommendations  broadly  advised against  the  use  of ecigarettes  without  making  distinctions  between nicotine  and THC  products  or  distinctions between youth  and adult use.  Our  econometric  results  suggest  that  an  unintended consequence  of this  approach  was  that most  people  did not perceive  the  extra  risks  of  THC products.  
  • More  targeted advice  about  the  risks  of  THC  e-cigarettes  might have  more  effectively  reduced  the  use  of  those  products,  potentially  preventing  EVALI  cases.

2020: Association of vaping‐related lung injuries with rates of e‐cigarette and cannabis use across US states (Links to PDF – 7 pages)

  • These findings are consistent with evidence linking theEVALI outbreak to vitamin E acetate and informally purchased or modified THC e‐liquids, as opposed to use of well‐established nicotine e‐cigarettes.

Cardiovascular Effects of Switching From Tobacco Cigarettes to Electronic Cigarettes – ScienceDirect

Teen e-cigarette use declined in 2020 – The Verge

Role of sweet and other flavours in liking and disliking of electronic cigarettes | Tobacco Control

Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked

Electronic Cigarette Use and Cigarette Abstinence Over 2 Years Among U.S. Smokers in the Population Assessment of Tobacco and Health Study – PubMed

Major Anti-Vaping Scientific Study Retracted | National Review

Changes in breathomics from a 1-year randomized smoking cessation trial of electronic cigarettes – PubMed

Electronic Cigarette Use and Cigarette Abstinence Over 2 Years Among U.S. Smokers in the Population Assessment of Tobacco and Health Study | Nicotine & Tobacco Research | Oxford Academic

Respiratory infections and pneumonia: potential benefits of switching from smoking to vaping | Pneumonia | Full Text

COPD smokers who switched to e-cigarettes: health outcomes at 5-year follow up – Ricardo Polosa, Jaymin B Morjaria, Umberto Prosperini, Barbara Busà, Alfio Pennisi, Mario Malerba, Marilena Maglia, Pasquale Caponnetto, 2020

Vapes more effective to quit smoking than gum or patch, …

Electronic cigarettes for smoking cessation – Hartmann-Boyce, J – 2020 | Cochrane Library

Cochrane Review: E-Cigarettes Appear More Effective Than Nicotine Replacement Therapy – American Vaping Association

Vaping less harmful than smoking for vascular health | University of DundeeE-cigarette Research

Have combustible cigarettes met their match? The nicotine delivery profiles and harmful constituent exposures of second-generation and third-generation electronic cigarette users | Tobacco Control

Francia incluye al cigarrillo electrónico en su estrategia para el mes sin tabaco 2020

Finalmente descobrimos se cigarros eletrônicos são melhores para a saúde do que os normais: estudo

Vaping & Nicotine Research by categories with summaries – Documentos Google

Documentary Exposes Global Nicotine Misinformation Campaign – Competitive Enterprise Institute

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