E-Cigarette and Vaping FAQs
FDA has described the use of e-cigarettes and vaping in youth as an epidemic.1 E-cigarettes were originally marketed as a strategy for adult smokers addicted to nicotine to have access to a noncombustible form of nicotine.2 There is no role for the use of e-cigarettes in youth.3 But e-cigarette products appeal to youth (even non-smokers) with their flavors, discreetness, designs, social media advertising, online videos, etc.4 In particular, pod e-cigarettes (e.g., Juul, Vuse, etc) have seen a dramatic increase in use by youth, currently accounting for more than half of e-cigarette sales.3 Juul has been described as the “iPhone of e-cigarettes.”4,5 These devices are small, discreet, and have been reportedly used undetected by students during classes.4,5 FDA and Health Canada are increasing regulations of e-cigarettes in an attempt to reduce their use in youth.1,6 New restrictions include trying to decrease youth access (with possible ban of online sales), bans on flavorings (e.g., bubblegum, cake batter, gummy bear, etc), restriction of marketing targeting youth, and education to the public on the dangers of e-cigarettes.1 Identifying e-cigarettes users can be tricky, as many people who “vape” do not identify themselves as smokers or even e-cigarette users.4 Ask youth about their use of “vaping” products, as this term seems to be more popular in this age group. The chart below answers common questions about vaping and e-cigarettes including use, safety, and regulations.
What are e-cigarettes?
E-cigarette is a common term for “electronic nicotine delivery systems (ENDS).” Other terms used include vaping devices, electronic cigarettes, electronic vapor products (EVPs), vape pens, e-cigars, e-hookah, etc.
The act of using these devices also has several descriptors; including vaping, Juuling, etc.4,7
Sizes and shapes of e-cigarettes vary (e.g., shaped like cigarettes, pens, flashlights, flash drives, etc).6-8
The device heats a liquid to produce an aerosolized vapor which is inhaled.
The liquids used may be called e-juice, e-liquid, etc.6,9 Other substances used include wax, salts, and herbs.6
E-cigarettes can be “opened” and refilled. Others are “closed,” using disposable cartridges, pods, mod pods, etc.
Most e-cigarettes contain nicotine however, there are some nicotine-free e-liquids.
Nicotine concentrations vary from very low to more than is found in tobacco cigarettes.10,11
Many e-cigarette products use “free-base” nicotine. However, higher nicotine concentrations of free-base nicotine are reported to cause “aversive user experiences.”9
Newer devices, (e.g., Juul) contain protonated nicotine, derived from nicotine salts in tobacco.9
How are e-cigarettes
E-cigarettes are marketed to be used for smoking cessation. In addition, they are also being used for recreation in persons who have never used tobacco cigarettes, particularly in youth.
E-cigarettes are also used in alternate ways (with and without nicotine); such as for smoke tricks (including competitions), inhalation of flavors, inhalation of other substances (e.g., marijuana), etc. There is an abundance of information on ways to use and manipulate these devices online and within social media.12
“Dripping” is one alternate use that may be increasing the danger of e-cigarettes. The e-liquid is dripped directly onto the heating coil of the device and the resulting vapor is inhaled quickly. Exposing the liquid to this higher temperature may increase the release of toxins (e.g., formaldehyde, acetaldehyde, acetone, etc) in the vapors. “Dripping” is reported to give users thicker clouds of vapor, improved flavor, and a stronger “throat hit” (which appears related to a certain [higher] level of nicotine). Higher temperatures may also increase the nicotine in the vapor, leading to higher nicotine serum levels.12
For “dabbing,” high-concentrations of cannabinoids (often tetrahydrocannabinol [THC] or cannabidiol [CBD]) are dropped onto the heating elements of e-cigarette devices.43
What are the
risks of nicotine in e-cigarettes?
Nicotine is highly addictive.3,6 Using e-cigarettes can cause addiction to nicotine.6
The adolescent brain is more susceptible to nicotine addiction than fully developed brains of adults.6,13
Nicotine alters brain development.6 It can affect cognitive function, memory, and attention when used while the brain is still developing into the mid-20s.3,5,6
There are no long-term data on the risks of nicotine delivered via e-cigarettes (e.g., heart, lungs, etc).15
Nicotine is absorbed in e-cigarette users. Approximate saliva concentration of a nicotine metabolite (cotinine):17
E-cigarettes are a source of secondhand exposure to nicotine and other chemicals. The risks of secondhand vapor are unknown but are expected to be lower than tobacco smoke. Caution is recommended around non-users, youth, pregnant women, people with cardiovascular conditions, etc.6,18
Severe lung disease associated with the used of e-cigarette products has been reported in hundreds of patients (mostly teenagers) in the U.S. CDC is investigating these cases and have confirmed at least six deaths as of September 12, 2019.44
E-cigarette use has also been linked to milder respiratory symptoms (cough, wheezing, etc).22
There is one case report of a previously healthy 18-year-old diagnosed with hypersensitivity pneumonitis after e-cigarette use.23
Analysis of common brands of e-cigarettes showed contents included propylene glycol, glycerol, glycerin, flavorings (e.g., diacetyl), diethylene glycol, ethylene glycol, ethanol, formaldehyde, and acrolein. The effect of chronic exposure to these chemicals is not known.6,19,20,47
There have been case reports of acute lipoid pneumonia associated with the inhalation of oil via e-cigarette devices.49
Seizures and other neurological symptoms (e.g., tremors) have been reported in patients using e-cigarettes. FDA is investigating these reports and their association with e-cigarettes.50
The Canadian Lung Association warns that urgent action must be taken to decrease vaping in youth and that inhaling e-cigarette vapor causes cough, wheezing, worsening of asthma symptoms, and unknown long-term effects.21
The American Lung Association has called for CDC and FDA to state that e-cigarettes are not safe, that they contain dangerous chemicals that can cause severe and irreversible lung damage and disease, and that the public should stop using e-cigarettes and vaping.51
The release of chemicals and contaminants (e.g., nickel, tin, aluminum, lead) in e-cigarette vapor varies between devices and the way they are used. More chemicals are released (e.g., formaldehyde [a known carcinogen], etc) at higher temperatures (e.g., with “dabbing” or “dripping” [described in the “How e-cigarettes are used” section above].6,12,14,20,48
Are youth who use
e-cigarettes at risk of becoming smokers?
Preliminary evidence suggests that youth who use e-cigarettes are more likely to smoke tobacco cigarettes and use cannabis at a later age than youth who don’t use e-cigarettes.24,25,4
effective for smoking cessation?
E-cigarettes are not an approved smoking cessation aid.
Some smokers claim that e-cigarettes make them “feel better” than when smoking tobacco cigarettes, that they save money, and that e-cigarettes help them to quit smoking.26
Some evidence supports the use of e-cigarettes to help patients quit smoking.2,6,27,28,42
Royal College of Physicians (U.K.) supports the use of e-cigarettes, in combination with behavioral therapy, in smokers who have tried other methods of quitting without success.29,30
Patients who want to quit smoking should be advised to use approved nicotine replacement products.
be used in public places?
Rules vary, but many public places (airplanes, hotels, etc) consider e-cigarettes and vaping within their no-smoking policies.32
E-cigarettes can trigger some types of smoke alarms.33
Rarely, e-cigarettes have been associated with explosions (due to the lithium battery) and fires causing serious burns and death.6,34
be used by hospitalized patients?
Many hospitals include e-cigarette use by patients and visitors in their no smoking policies.35
Patients who use e-cigarettes may experience a withdrawal syndrome from nicotine.
Hospitalized patients who cannot use e-cigarettes should be offered nicotine replacement therapy if needed. The amount of nicotine in e-cigarettes can vary. Some hospital nicotine replacement protocols recommend starting e-cigarette patients on low-dose nicotine replacement therapy, then monitoring and titrating as needed.
poisonings with e-cigarettes?
The flavorings of e-liquids and designs of the devices are very appealing to children. They must be kept in a safe place, out of reach of children and pets.6
As e-cigarettes have become more popular, poison centers report an increasing number of exposures to nicotine-containing e-liquids, from 271 cases in 2011 to 3,073 cases in 2015.36
Commercially available e-liquids can contain up to 100 mg/mL of nicotine.
Just 1 mg of nicotine can cause adverse symptoms in a toddler, and 6 mg/kg to 13 mg/kg can be lethal.37,38
Poisonings from e-liquids are reported from ingestion, skin contact, or by inhalation.39
Symptoms of nicotine toxicity can include nausea, vomiting, diarrhea, salivation, weakness, hypertension, and tachycardia. In severe cases; seizures, coma, and death can occur.40
Use caution when handling e-liquids to avoid skin exposure, due to the potential for topical nicotine absorption.
Regulations for e-cigarettes and vaping are evolving.
FDA and Health Canada regulate all aspects of e-cigarettes and vaping products; including packaging, promotion, banning of ingredients or devices, etc.1,6
Vaping products with nicotine are available to adults as an alternative to smoking.6
E-cigarettes are not able to be purchased by those younger than 18 years of age in Canada and the U.S.6,41
Healthcare professionals are also calling for regulations on these devices that may prevent them from being manipulated for alternative uses (e.g., dripping, etc).12
is available to help educate patients about the risks of e-cigarettes?
CDC and Health Canada offer information sheets to help parents talk with their teenagers about e-cigarettes (https://e-cigarettes.surgeongeneral.gov/documents/SGR_ECig_ParentTipSheet_508.pdf and https://www.canada.ca/en/services/health/publications/healthy-living/talking-teen-vaping-tip-sheet-parents.html).
FDA has expanded its Youth Tobacco Prevention Plan to include tools to help prevent vaping in youth with The Real Cost of Vaping (http://www.scholastic.com/youthvapingrisks/).
There are little data on effective strategies to quit e-cigarettes. Patients can consider traditional smoking cessation strategies, but keep in mind that even data for smoking cessation in teenagers are limited. See our toolbox, Smoking Cessation: Helping Patients Who Use Tobacco, for practical tips and resources.
Project Leader in preparation of this clinical resource (341102): Annette Murray, BScPharm; last modified September 2019.
- FDA. Statement from FDA commissioner Scott Gottlieb, M.D., on new steps to address epidemic of youth e-cigarette use. September 12, 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm620185.htm. (Accessed October 7, 2018).
- Hartmann-Boyce J, Begh R, Aveyard P. Electronic cigarettes for smoking cessation. BMJ 2018;360:j5543.
- CDC. Sales of JUUL e-cigarettes skyrocket, posing danger to youth. October 2, 2018. https://www.cdc.gov/media/releases/2018/p1002-e-Cigarettes-sales-danger-youth.html. (Accessed October 5, 2018).
- Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tob Control 2019;28:146-51.
- Koval R, Willett J, Briggs J. Potential benefits and risks of high-nicotine e-cigarettes. JAMA 2018;320:1429-30.
- Government of Canada. Vaping. June 27, 2018. https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping.html. (Accessed October 5, 2018).
- American Academy of Pediatrics. Electronic nicotine delivery systems. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Richmond-Center/Pages/Electronic-Nicotine-Delivery-Systems.aspx. (Accessed October 4, 2018).
- Demissie Z, Everett Jones S, Clayton HB, King BA. Adolescent risk behaviors and use of electronic vapor products and cigarettes. Pediatrics 2017 Feb. doi: 10.1542/peds.2016-2921.
- Barrington-Trimis JL, Leventhal AM. Adolescents’ use of “pod mod” e-cigarettes – urgent concerns. N Engl J Med 2018;379:1099-1102.
- Trimarchi M, Cassidy S. 10 little-known facts about e-cigarettes. Howstuffworks.com. http://health.howstuffworks.com/wellness/smoking-cessation/10-facts-about-e-cigarettes.htm. (Accessed October 7, 2018).
- Schroeder MJ, Hoffman AC. Electronic cigarettes and nicotine clinical pharmacology. Tob Control 2014;23(Suppl 2):ii30-5.
- Krishnan-Sarin S, Morean M, Kong G, et al. E-cigarettes and “dripping” among high-school youth. Pediatrics 2017 Mar. doi: 10.1542/peds.2016-3224.
- Truth Initiative. 4 things parents need to know about JUUL and nicotine addiction. August 17, 2018. https://truthinitiative.org/news/4-things-parents-need-know-about-juul-and-nicotine-addiction. (Accessed October 6, 2018).
- Olmedo P, Goessler W, Tanda S, et al. Metal concentrations in e-cigarette liquid and aerosol samples: the contribution of metallic coils. Environ Health Perspect 2018;126:027010.
- Canadian Lung Association. E-cigarettes. July 2018. https://www.lung.ca/news/expert-opinions/e-cigarettes. (Accessed October 7, 2018).
- Moheimani RS, Bhetraratana M, Yin F, et al. Increased cardiac sympathetic activity and oxidative stress in habitual electronic cigarette users: implications for cardiovascular risk. JAMA Cardiol 2017;2:278-84.
- Etter JF. Levels of saliva cotinine in electronic cigarette users. Addiction 2014;109:825-9.
- Czogala J, Goniewicz ML, Fidelus B, et al. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res 2014;16:655–62.
- Varlet V, Farsalinos K, Augsburger M, et al. Toxicity assessment of refill liquids for electronic cigarettes. Int J Environ Res Public Health 2015;12:4796-815.
- Jensen RP, Luo W, Pankow JF, et al. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med 2015;372:392-4.
- Canadian Lung Association. Statement: vaping and lung disease. August 23, 2019. https://www.lung.ca/news/latest-news/statement-vaping-and-lung-disease. (Accessed September 16, 2019).
- Ontario Campaign for Action on Tobacco. Heath groups alarmed at government proposal to allow display of vaping products in thousands of retail outlets. October 2, 2018. http://www.ocat.org/pdf/OCAT-VapingRegsNewsReleaseOct2018.pdf. (Accessed October 7, 2018).
- Sommerfeld CG, Weiner DJ, Nowalk A, Larkin A. Hypersensitivity pneumonitis and acute respiratory distress syndrome from e-cigarette use. Pediatrics 2018 Jun. doi: 10.1542/peds.2016-3927.
- Primack BA, Soneji S, Stoolmiller M, et al. Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatr 2015;169:1018-23.
- Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr 2017;171:788-97.
- Syamlal G, Jamal A, King BA, Mazurek JM. Electronic cigarette use among working adults — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:557-61.
- Bullen C. Electronic cigarettes for smoking cessation. Curr Cardiol Rep 2014;16:538.
- Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013;382:1629-37.
- Hajek P, McRobbie H. E-cigarettes an evidence update. A report commissioned by Public Health England. 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf. (Accessed October 7, 2018).
- Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. April 28, 2016. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0. (Accessed October 7, 2018).
- Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: a policy statement from the American Heart Association. Circulation 2014;130:1418-36.
- Transportation Security Administration. E-cigarettes and other nicotine delivery systems. May 6, 2016. https://www.tsa.gov/blog/2016/05/06/asktsa-travel-tips-over-140-characters-e-cigarettes-and-other-nicotine-delivery. (Accessed October 5, 2018).
- Anon. Do e-cigarettes set off fire alarms? January 15, 2018. https://www.blu.com/en/US/blog/vaping-tips/do-ecigarettes-set-off-fire-alarms.html?countryselect=true. (Accessed October 5, 2018).
- U.S. Fire Administration. Electronic cigarette fires and explosions in the United States 2009-2016. July 2017. https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf. (Accessed October 5, 2018).
- Meernik C, Baker HM, Paci K, et al. Electronic cigarettes on hospital campuses. Int J Environ Res Public Health 2015 Dec 29. Doi: 10.3390/ijerph13010087.
- American Association of Poison Control Centers. Electronic cigarettes and liquid nicotine data. January 31, 2016. https://aapcc.org. (Accessed October 4, 2018).
- Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Arch Toxicol 2014;88:5-7.
- Walley SC, Jenssen BP; Section on Tobacco Control. Electronic nicotine delivery systems. Pediatrics 2015;136:1018-26.
- Kamboj A, Spiller HA, Casavant MJ, et al. Pediatric exposure to e-cigarettes, nicotine, and tobacco products in the United States. Pediatrics 2016 Jun. doi:10.1542/peds.2016-0041.
- Chatham-Stephens K, Law R, Taylor E, et al. Notes from the field: calls to poison centers for exposures to electronic cigarettes — United States, September 2010–February 2014. MMWR Morb Mortal Wkly Rep 2014;63;292-3.
- FDA, HHS. Deeming tobacco products to be subject to the Federal Food, Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products. Final rule. Fed Regist 2016;81:28973-9106.
- Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med 2019;380:629-37.
- Young K. Feds eyeing unauthorized vaping products in outbreak of severe lung disease. September 3, 2019. https://www.jwatch.org/fw115776/2019/09/03/feds-eyeing-unauthorized-vaping-products-outbreak-severe?query=pfwTOC&jwd=000020043017&jspc=GP. (Accessed September 8, 2019).
- CDC. Outbreak of lung disease associated with e-cigarette use, or vaping. September 12, 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. (Accessed September 17, 2019).
- Health Canada. Information update – Health Canada warns of potential risk of pulmonary illness associated with vaping products. September 4, 2019. https://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/70919a-eng.php. (Accessed September 8, 2019).
- Layden JE, Ghinai MB, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary report. N Engl J Med 2019 Sept 6. doi: 10.1056/NEJMoa1911614.
- Fadus MC, Smith TT, Squeglia LM. The rise of e-cigarettes, pod mod devices, and JUUL among youth: factors influencing use, health implications, and downstream effects. Drug Alcohol Depend 2019;201:85-93.
- Government of Canada. Risks of vaping. July 31, 2019. https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/risks.html. (Accessed September 9, 2019).
- Davidson K, Brancato A, Heetderks P, et al. Outbreak of electronic-cigarette-associated acute lipoid pneumonia– North Carolina, July – August 2019. September 6, 2019. https://www.cdc.gov/mmwr/volumes/68/wr/mm6836e1.htm?s_cid=mm6836e1_w. (Accessed September 9, 2019).
- FDA. FDA in brief: FDA encourages continued submission of reports related to seizures following e-cigarette use as part of agency’s ongoing scientific investigation of potential safety issue. August 7, 2019. https://www.fda.gov/news-events/fda-brief/fda-brief-fda-encourages-continued-submission-reports-related-seizures-following-e-cigarette-use. (Accessed September 10, 2019).
- American Lung Association. American Lung Association calls on Federal Government to deliver a clear message: don’t vape or use e-cigarettes. August 30, 2019. https://www.lung.org/about-us/media/press-releases/deliver-clear-message-do-not-vape.html. (Accessed September 16, 2019).
Cite this document as follows: Clinical
Resource, E-Cigarette and Vaping FAQs. Pharmacist’s Letter/Prescriber’s Letter. November 2018.