Health Advisory Notice for Healthcare Providers

Important Information Relating to Electronic Cigarettes, Electronic Nicotine Delivery Systems (ENDS) and Other Vapor Products

In the last several years, Electronic Nicotine Delivery Systems (ENDS) have begun to penetrate the Arkansas environment. These devices, also known as e-cigarettes, e-cigars, vaping devices, e-hookah, etc., usually have some type of nicotine base in a suspension (such as propylene glycol or glycerin) often mixed with flavorings including menthol.

ENDS contain nicotine, a tobacco product under current definitions, and not a therapeutic product. Unofficially, they have been promoted as cessation aids with claims of reduced harm and safety in the public space. The FDA, under the tobacco control act and subsequent decisions, has the authority to regulate ENDS and has begun the process of submitting regulatory documents. Because of the extensive process and expected pushback from the ENDS industry, no official guidance is expected in the short run.

There is evidence that adolescents are aware of ENDS and are using them, including adolescents with no prior tobacco use. Further, the promotion of ENDS in both marketing and flavoring has increased impact among children. The current science addressing the unofficial claims regarding safety and cessation is accelerating and raises concerns about these claims.

Safety:

  • For those who use ENDS, there is clear ongoing exposure to nicotine. Nicotine is a recognized toxic agent associated with overdoses which happen when children consume tank fluids.
  • Because these products are currently unregulated, wide variation in product concentrations of nicotine exist
  •  Adequate long term studies are not available to preclude a relationship of ENDS to cardiovascular disease
  • Non-nicotine toxicants are generated from the heating of the ENDS solutions. Products identified to date include low levels of formaldehyde, a series of volatile organic compounds and some carcinogens including nitrosamines. To date, there is limited human data on the acute or long term consequences.
  • Absorption of nicotine in non-smoking people exposed to ENDS vapor has been documented.
  • ENDS vapor has been preliminarily reported to condense in the environment and residue can be found on carpet, glass and other surfaces, creating a risk for crawling infants and pets and ultimately creating a toxic dust.
  • ENDS have been adapted for use of other non-tobacco substances such as marijuana, cocaine and methamphetamine solutions in tank systems.

Cessation:

  • ENDS have not been demonstrated to be effective for cessation or to be superior to current safe and effective FDA approved nicotine replacement therapies.
  • Some studies show decreased effectiveness of cessation treatments when clients are using ENDS.

Public Policy:

  • Confusion in environments where clean indoor air laws apply has developed since ENDS are often misidentified as cigarettes.
  • ENDS are being promoted to re-normalize smoking behaviors and reverse clean indoor air gains.
  • Some national organizations have released policy statements on ENDS, including the American Academy of Pediatrics in December 2013, suggesting that ENDS should be treated like other combustible tobacco products and that sales to minors should be prohibited. The World Health Organization (WHO) in July 2013, advised that consumers not use ENDS until safety has been demonstrated.

Medical Practice:

  • According to a preliminary report in North Carolina, heavy promotion and misunderstanding of ENDS has led providers to promote these products. In one survey, two of three physicians believed that ENDS helped with cessation and one of three prescribed ENDS for their patients. Thirteen per cent believed they were regulated by the FDA.

Summary Findings:

  • ENDS are toxic products with demonstrated release of toxicants into the indoor environment.
  • ENDS have not been proven to assist in cessation outside of laboratory environments and may actually reduce cessation success.
  • ENDS contribute to confusion about enforcement of clean indoor air laws.

Recommendations:

  • Clean air regulations should apply to ENDS as well as other combustible tobacco products.
  • Promotion of ENDS as cessation devices should be restricted until additional data are available.

References:

American Academy of Pediatrics. (2013, December). State Advocacy Focus: E-Cigarettes. Retrieved from http://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/E-Cigarettes.pdf

Goneweicz ML et al. (2013). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control.

Lee L et al. (2014, February 8). Assessment of thirdhand exposure to nicotine from electronic cigarettes. Lecture POS1-6 at Society for Nicotine Research and Treatment. Seattle, WA.

Luo C. et al. (2014, February 4). Content and youth access of electronic cigarette videos on you tube. Poster POS1- 69 at Society for Nicotine Research and Treatment. Seattle, WA.

Centers for Disease Control and Prevention. (2013, September 6). Notes from the Field: Electronic Cigarette Use Among Middle and High School Students – United States, 2011-2012. Morbidity and Mortality Weekly Report, 62(35), 729-730.

Ranney L et al. (2014, February 4). Physician use of e-cigarettes as cessation devices, North Carolina 2013. Poster POS1-23 at Society for Nicotine Research and Treatment. Seattle, WA.

Vickerman KA et al. (2013, October). Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine Tobacco Research, 15(10):1787-91.

World Health Organization. (2013, July 9). Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS). Retrieved from http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/