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A systematic review of health effects of electronic cigarettes

Highlights
No firm conclusions can be drawn on the safety of electronic cigarettes.
The findings in the 76 studies were often inconsistent and contradictory.
Serious methodological problems were identified and there is no long-term follow-up.
In 34% of the articles the authors had a conflict of interest.
Electronic cigarettes can hardly be considered harmless.

Published: 16 October 2014

Positive: No

Link to publication: http://www.sciencedirect.com/science/article/pii/S0091743514003739

Authors

Charlotta Pisingera
Martin Døssingb


Summary

Objective

To provide a systematic review of the existing literature on health consequences of vaporing of electronic cigarettes (ECs).

Methods

Search in: Pub Med, EMBASE and CINAHL. Inclusion criteria: Original publications describing a health-related topic, published before 14 August 2014. PRISMA recommendations were followed. We identified 1101 studies; 271 relevant after screening; 94 eligible.

Results

We included 76 studies investigating content of fluid/vapor of ECs, reports on adverse events and human and animal experimental studies. Serious methodological problems were identified. In 34% of the articles the authors had a conflict of interest. Studies found fine/ultrafine particles, harmful metals, carcinogenic tobacco-specific nitrosamines, volatile organic compounds, carcinogenic carbonyls (some in high but most in low/trace concentrations), cytotoxicity and changed gene expression. Of special concern are compounds not found in CCs, e.g. propylene glycol. Experimental studies found pulmonary obstruction after short-term exposure. Reports on short-term adverse events were often flawed by selection bias.


Conclusions

Due to many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up no firm conclusions can be drawn on the safety of ECs. However, they can hardly be considered harmless.


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Particulate Metals and Organic Compounds from Electronic and Tobaccocontaining Cigarettes: Comparison of Emission Rates and Secondhand Exposure

Particulate metals and organic compounds from electronic and tobacco-containing cigarettes: comparison of emission rates and secondhand exposure

Published: 22 August 2014

Positive: No

Link to publication: http://pubs.rsc.org/en/content/articlelanding/2014/em/c4em00415a#!divAbstract

Authors

Arian Saffari, Nancy Daher, Ario Ruprecht, Cinzia De Marco, Paolo Pozzi, Roberto Boffi, Samera H. Hamad, Martin M. Shafer, James J. Schauer, Dane Westerdahle and Constantinos Sioutas


Summary

In recent years, electronic cigarettes have gained increasing popularity as alternatives to normal (tobacco-containing) cigarettes. In the present study, particles generated by e-cigarettes and normal cigarettes have been analyzed and the degree of exposure to different chemical agents and their emission rates were quantified. Despite the 10-fold decrease in the total exposure to particulate elements in e-cigarettes compared to normal cigarettes, specific metals (e.g. Ni and Ag) still displayed a higher emission rate from e-cigarettes. Further analysis indicated that the contribution of e-liquid to the emission of these metals is rather minimal, implying that they likely originate from other components of the e-cigarette device or other indoor sources. Organic species had lower emission rates during e-cigarette consumption compared to normal cigarettes. Of particular note was the non-detectable emission of polycyclic aromatic hydrocarbons (PAHs) from e-cigarettes, while substantial emission of these species was observed from normal cigarettes. Overall, with the exception of Ni, Zn, and Ag, the consumption of e-cigarettes resulted in a remarkable decrease in secondhand exposure to all metals and organic compounds. Implementing quality control protocols on the manufacture of e-cigarettes would further minimize the emission of metals from these devices and improve their safety and associated health effects.


Conclusion

Analysis of secondhand emissions from a popular and widely-used e-cigarette brand indicated a very large reduction of particle-phase emissions compared to normal tobacco-containing cigarettes in a real-life setting. BC and particle-phase PAHs, deleterious chemical species present in high concentrations in tobacco smoke, were not detected in e-cigarette’s aerosol. Emission rates of organic compounds (including alkanes and organic acids) as well as total emission of inorganic elements and metals were also significantly reduced (more than100 times for organics and 10 times for elements) in e-cigarettes compared to normal cigarettes. Analysis of elemental emissions indicated the presence of toxic metals (such as Ni, Zn and Ag) in e-cigarette’s aerosol, with Ni and Ag having higher indoor emission rates compared to normal cigarettes. Moreover,analysis of nicotine indicated that secondhand particle-phase nicotine accounted for about 0.02% of the total nicotine generation and emission during e-cigarette vaping. Based on our results, use of e-cigarettes from a public health perspective appears to be an improvement compared to normal tobacco-containing cigarettes, as exposure to most of the toxic and/or undesirable chemical species was found to be much lower than that for normal cigarettes. However, considering the lack of regulation on the manufacturing process of e-cigarettes, there appears to be a potential for utilization of toxic material (such as metals) in e-cigarettes, which could lead to their emission in e-cigarette’s vapor and aerosol.1,13Implementing quality control regulations on the design and manufacturing process of e-cigarettes is therefore necessary to prevent potential utilization of non-desirable material in e-cigarettes and e-liquids.


Complete study: Particulate metals and organic compounds from (study in pdf)

Particulate (additional information on the study in pdf)

Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol

The filament, a nickel-chromium wire, was coupled to a thicker copper wire coated with silver. The silver coating was sometimes missing. Four tin solder joints attached the wires to each other and coupled the copper/silver wire to the air tube and mouthpiece. All cartomizers had evidence of use before packaging (burn spots on the fibers and electrophoretic movement of fluid in the fibers). Fibers in two cartomizers had green deposits that contained copper. Centrifugation of the fibers produced large pellets containing tin. Tin particles and tin whiskers were identified in cartridge fluid and outer fibers. Cartomizer fluid with tin particles was cytotoxic in assays using human pulmonary fibroblasts. The aerosol contained particles >1 µm comprised of tin, silver, iron, nickel, aluminum, and silicate and nanoparticles (<100 nm) of tin, chromium and nickel. The concentrations of nine of eleven elements in EC aerosol were higher than or equal to the corresponding concentrations in conventional cigarette smoke. Many of the elements identified in EC aerosol are known to cause respiratory distress and disease.

Published: 20 March 2013

Positive: No

Link to publication: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0057987

Reply from Dr Siegel: http://tobaccoanalysis.blogspot.be/2013/04/metals-in-electronic-cigarette-vapor.html

Authors

Monique Williams
Amanda Villarreal
Krassimir Bozhilov
Sabrina Lin
Prue Talbot


Summary

We tested the hypothesis that EC aerosol contains metals derived from various components in EC.

Cartomizer contents and aerosols were analyzed using light and electron microscopy, cytotoxicity testing, x-ray microanalysis, particle counting, and inductively coupled plasma optical emission spectrometry.


Conclusions

The presence of metal and silicate particles in cartomizer aerosol demonstrates the need for improved quality control in EC design and manufacture and studies on how EC aerosol impacts the health of users and bystanders.


 

Complete study: Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol (pdf)

Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study

Vape Vs NRTs Vs cold turkey. 20% cessation with vape, 10% with NRTs

Published: 12 May 2014

Positive: Yes

Link to publication: http://onlinelibrary.wiley.com/doi/10.1111/add.12623/pdf

Link to press release (FR): http://www.pourquoidocteur.fr/La-e-cigarette-fait-la-preuve-de-son-efficacite-pour-arreter-de-fumer–7757.html

Authors:

Jamie Brown

Emma Beard

Daniel Kotz

Susan Michie

Robert West


Summary

Background and Aims

Electronic cigarettes (e-cigarettes) are rapidly increasing in popularity. Two randomized controlled trials have suggested that e-cigarettes can aid smoking cessation, but there are many factors that could influence their real-world effectiveness.

This study aimed to assess, using an established methodology, the effectiveness of e-cigarettes when used to aid smoking cessation compared with nicotine replacement therapy (NRT) bought over-the-counter and with unaided quitting in the general population.

Design and Setting

A large cross-sectional survey of a representative sample of the English population.

Participants

The study included 5863 adults who had smoked within the previous 12 months and made at least one quit attempt during that period with either an e-cigarette only(n=464), NRT bought over-the-counter only (n=1922) or no aid in their most recent quit attempt (n=3477).

Measurements

The primary outcome was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including nicotine dependence.

Findings

E-cigarette users were more likely to report abstinence than either those who used NRT bought over-the-counter [odds ratio (OR)=2.23, 95% confidence interval(CI)=1.70–2.93, 20.0 versus 10.1%] or no aid (OR=1.38, 95% CI=1.08–1.76, 20.0 versus 15.4%). The adjusted odds of non-smoking in users of e-cigarettes were 1.63 (95% CI=1.17–2.27) times higher compared with users of NRT bought over-the-counter and 1.61 (95% CI=1.19–2.18) times higher compared with those using no aid


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


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Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit

We reviewed available research on the use, content and safety of electronic cigarettes (EC), and on their effects on users, to assess their potential for harm or benefit and to extract evidence that can guide future policy.

Published: 31 July 2014

Positive: Yes

Link to publication: http://onlinelibrary.wiley.com/doi/10.1111/add.12659/abstract

Authors

Peter Hajek
Jean-François Etter
Neal Benowitz
Thomas Eissenberg
Hayden McRobbie


Summary

EC aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower. Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children. EC enable some users to reduce or quit smoking.


Conclusion

Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality. Regulating EC as strictly as cigarettes, or even more strictly as some regulators propose, is not warranted on current evidence. Health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.


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Effectiveness and tolerability of electronic cigarette in real-life: a 24-month prospective observational study

This prospective observational study evaluated smoking  reduction/abstinence in smokers not intending to quit using an e-Cigarette (‘Categoria’; Arbi Group, Italy).

Published 20 July 2013

Positive: Yes

Link to publication: http://link.springer.com/article/10.1007%2Fs11739-013-0977-z

Authors

  • Riccardo Polosa,
  • Jaymin B. Morjaria,
  • Pasquale Caponnetto,
  • Davide Campagna,
  • Cristina Russo,
  • Angela Alamo,
  • MariaDomenica Amaradio,
  • Alfredo Fisichella

 

Summary

Electronic cigarettes (e-Cigarette) are battery-operated devices designed to vaporise nicotine that may aid smokers to quit or reduce their cigarette consumption. Research on e-Cigarettes is urgently needed to ensure that the decisions of regulators, healthcare providers and consumers are evidence based. Here we assessed long-term effectiveness and tolerability of e-Cigarette used in a ‘naturalistic’ setting. This prospective observational study evaluated smoking reduction/abstinence in smokers not intending to quit using an e-Cigarette (‘Categoria’; Arbi Group, Italy). After an intervention phase of 6 months, during which e-Cigarette use was provided on a regular basis, cigarettes per day (cig/day) and exhaled carbon monoxide (eCO) levels were followed up in an observation phase at 18 and 24 months. Efficacy measures included: (a) ≥50 % reduction in the number of cig/day from baseline, defined as self-reported reduction in the number of cig/day (≥50 %) compared to baseline; (b) ≥80 % reduction in the number of cig/day from baseline, defined as self-reported reduction in the number of cig/day (≥80 %) compared to baseline; (c) abstinence from smoking, defined as complete self-reported abstinence from tobacco smoking (together with an eCO concentration of ≤10 ppm). Smoking reduction and abstinence rates were computed, and adverse events reviewed.


 

Conclusion

Of the 40 subjects, 17 were lost to follow-up at 24 months. A >50 % reduction in the number of cig/day at 24 months was shown in 11/40 (27.5 %) participants with a median of 24 cig/day use at baseline decreasing significantly to 4 cig/day (p = 0.003). Smoking abstinence was reported in 5/40 (12.5 %) participants while combined >50 % reduction and smoking abstinence was observed in 16/40 (40 %) participants at 24 months. Five subjects stopped e-Cigarette use (and stayed quit), three relapsed back to tobacco smoking and four upgraded to more performing products by 24 months. Only some mouth irritation, throat irritation, and dry cough were reported. Withdrawal symptoms were uncommon. Long-term e-Cigarette use can substantially decrease cigarette consumption in smokers not willing to quit and is well tolerated.


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