Q1: What are e-cigarettes and how do they work?
A: Electronic nicotine delivery systems (ENDS) are noncombustible battery-operated devices that heat a liquid to produce an aerosol, composed of nicotine and various other chemicals, which is inhaled by the user through a mouthpiece. ENDS devices come in various forms and are often designed to mimic the look of combustible tobacco products, e.g. e-cigarettes, e-cigars, e-pipes, or e-shisha/hookah. They are commonly referred to as e-cigarettes and vapes or vape pens. The liquids used in ENDS (commonly called e-liquid or e-juice) typically contain nicotine, flavorings, and other ingredients like propylene glycol and vegetable glycerin.[i],[ii]
Heated tobacco products (HTPs) heat tobacco, sometimes in combination with e-liquid, to produce a chemical aerosol similar to tobacco smoke. HTPs generate heat with or without an electronically controlled heating system.
Q2: Is it true that heating (not burning) e-liquids or tobacco does not release harmful chemicals?
A: Heating e-liquids in ENDS or tobacco (with or without e-liquid) in HTPs creates an aerosol composed of nicotine and various carcinogens and toxic chemicals, many of which are also found in tobacco smoke. Burning has also been observed in the wicks and heating coils of ENDS and in the tobacco sticks of HTPs.
Q3: Are e-cigarettes really 95% safer than cigarettes?
A: No. This claim of reduced harm is made on the basis of lower concentrations of toxicants found in ENDS and HTP aerosols when compared to conventional cigarette smoke; however, reduced exposure to these toxicants does not necessarily equate to reduced risk, and there is still no long term scientific evidence to support this claim. The World Health Organization (WHO) has consistently warned that all tobacco products, including HTPS, are harmful[iii] and recently (July 2019) declared that e-cigarettes are “undoubtedly harmful” and not a safer alternative to conventional cigarettes.[iv]
Q4: Some experiments on mice show that e-cigarettes cause various diseases, including cancer. Are these studies relevant for humans?
A: When experiments in mice in the 1950s first established the clear link between cigarette smoking and cancer, tobacco companies also denied the evidence. E-cigarette vapor causes lung cancer and potentially bladder cancer in mice, damaging their DNA and leading researchers at New York University (NYU) to conclude that vaping is likely “very harmful” to humans as well. In the NYU study, researchers found that e-cigarette vapor caused DNA damage in the lungs and bladder and “inhibits DNA repair in lung tissues.” These findings should not be dismissed as being irrelevant to humans.[v]
Q5: Is nicotine as harmless as caffeine?
A: Various industry documents, court testimony, and advertisements show that the tobacco industry has been working for decades to equate nicotine with harmless consumer products such as coffee, tea, or gummy bears. This effort to dissociate nicotine from addictive and harmful drugs (such as heroin or cocaine) that was previously used to normalize conventional cigarettes is now being applied to e-cigarettes. However, the vast majority of people don’t become addicted to caffeine. According to Neal Benowitz, a pharmacologist and professor at the University of California, San Francisco, “if a doctor tells someone to switch to decaf, most people can…. But people have a harder time ignoring nicotine cravings when they’re trying to stop smoking.”[vi]
Nicotine also increases the risk of cardiovascular, respiratory, gastrointestinal, and reproductive and perinatal disorders, suppresses the immune response, and plays a clear role in cancer growth.[vii] It also impairs adolescent brain maturation with both short-term and long-term consequences for teen addiction, cognition, and emotional regulation.[viii], [ix]
Q6: Is second-hand exposure to e-cigarette aerosols dangerous?
A: Given the chemical profile of ENDS and HTP aerosols, there is a potential risk of harm from secondhand exposure, even when emissions are not clearly visible. Both the WHO and US National Academies of Sciences, Engineering, and Medicine (NASEM) have determined that there is conclusive evidence that exhaled e-cigarette aerosols increase airborne concentrations of particulate matter, nicotine, and some toxicants compared with background levels.[x], [xi] While very limited studies have examined the health risks of passive exposure to e-cigarette aerosols, a systematic review of evidence concluded that passive exposure to the air pollutants in ENDS aerosols is at concentrations associated with potential adverse health effects.[xii], [xiii]
Q7: Can e-cigarettes help smokers quit smoking?
A: While some vaping proponents argue that vaping is an effective smoking cessation tool, population-level studies show that majority of e-cigarette users are dual users (using both conventional and electronic cigarettes) and that e-cigarette use blocks or delays actual cessation.[xiv] Even manufacturers of ENDS and HTPs state that their products are switching products (from smoking conventional cigarettes to smoking electronic ones) and not intended to be smoking cessation products.[xv]
If conventional cigarettes were to be introduced into the consumer market today, they would never be approved for sale. Unfortunately, they were allowed for sale and legalized at a time when there was still no evidence of their safety or harm. This was a historical mistake that worldwide has led to a staggering 1.2 billion tobacco users and now costs eight million people their lives each year. Governments must act swiftly and not make the same mistake for e-cigarettes.
Q8: E-cigarettes have been in the US market for more than 10 years, why are people getting sick only now?
A: People may have been getting sick earlier, but their sickness was not recognized at the time as being caused by e-cigarettes. The US Centers for Disease Control and Prevention (CDC) have now identified a clear link between serious lung injury and e-cigarette use: e-cigarette or vaping product use-associated lung injury (EVALI).[xvi] As of November 5, 2019, 2,051 cases of EVALI, including 39 deaths, have been reported in the USA. The CDC has now issued guidance to health care providers on this injury, which was not commonly recognized before. However, case reports of similar lung injuries exist from as early as 2011.
Q9: Why are e-cigarette users in the US getting sick but not in other countries?
A: There have been 74 health problems (49 classified as “serious”),[xvii] one hospital admission, and possibly one death linked to e-cigarettes use in the UK.[xviii] Elsewhere there have been reports of one hospital admission in Malaysia[xix] and one in Canada[xx] linked to ENDS and two cases in Japan linked to HTP use. There is always the possibility that the number of EVALI incidence and deaths may increase in other countries as people continue to use e-cigarettes and as more doctors and nurses recognize the disease.
Q10: Isn’t THC (tetrahydrocannabinol) vaping the actual cause of the outbreak of lung diseases in the US?
A: According to the US CDC, all EVALI patients have reported a history of using e-cigarette, or vaping, products. While most patients report using THC vape products, particularly those obtained off the street or from other informal sources, some patients have reported using only nicotine-containing products. In addition:
- No one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak. Many different substances and product sources are still under investigation.
- While it appears that vitamin E acetate is associated with EVALI, evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI.[xxi]
Q11: The teen vaping epidemic in the US is due to bad parenting. Why is the vaping industry being blamed?
A: It is convenient to blame poor parenting for vaping. In reality the vaping industry has been targeting and luring teenagers with dishonest advertising campaigns and kid-friendly flavors, and both parents and teens have been misled on the harmful effects of e-cigarettes on health.[xxii]While the Office of the US Surgeon General now provides updated information on its website to educate and alert parents to convince their children not to vape,[xxiii] the vaping industry has resisted US government regulatory efforts in the past[xxiv] and continues to do so.
Q12: How many countries ban e-cigarettes?
A: More than 40 countries currently ban ENDS and HTPs, including five (5) ASEAN countries: Brunei, Cambodia, Lao PDR, Singapore and Thailand.
Q13: If e-cigarettes are banned, will people will go back to smoking?
A: Prior to the advent of e-cigarettes, the alternative for smokers was to quit smoking and breathe in only air. This is still the best alternative, and all smokers are capable of quitting smoking without switching to ENDS/HTPs. Governments should be promoting tobacco cessation and relapse prevention to help smokers achieve long-term abstinence and freedom from nicotine addiction.
Q14: Why are some countries banning e-cigarettes but not cigarettes?
A: While there is still no long term evidence of the safety or relative risk of e-cigarette use, health research has already confirmed the serious addiction and health risks of e-cigarettes. Banning these products based on the precautionary principle is warranted to protect the health of people. Governments should learn from the regulatory mistakes of the tobacco pandemic, which was allowed to proliferate and currently is addicting over a billion people worldwide. Banning e-cigarettes is the strictest form of regulation and is recommended in cases where regulatory capacity or enforcement is relatively weak. Governments should prioritize and accelerate tobacco control measures in line with the WHO FCTC to fast track the tobacco endgame and eventually ban the sale of traditional cigarettes.
Q15: Why are flavors in e-cigarettes being targeted for regulations?
A: Flavored products, particularly sweet and fruity ones, such as bubble gum, cotton candy, gummy bear, and cola, are clearly attractive to youths Most youths who smoke e-cigarettes use a flavored product.[xxv]
Q16: How have e-cigarettes been marketed to children and young people?
A: Youths are exposed to e-cigarette product marketing through a range of channels, including social media/social influencers, product displays in stores, and ads outside of stores.[xxvi] Very similar to cigarette ads that are now banned in many countries, e-cigarette ads are associated with youth, fun, success, and sensuality.[xxvii]
Q17: What’s Big Tobacco’s role in e-cigarettes?
A: All major tobacco companies, such as Philip Morris International (PMI), Altria/Philip Morris USA, British American Tobacco (BAT), Japan Tobacco International, (JTI), Imperial Brands, and RJ Reynolds produce their own brands of ENDS and HTPs.[xxviii]
|Company||ENDS brands||HTP brands|
|Philip Morris International (PMI)||Nicocig, Vivid, IQOS MESH||IQOS, TEEPS|
|Altria/Philip Morris USA||Mark Ten,* Green Smoke,* owns 35% of Juul||Sells PMI’s IQOS in USA|
|British American Tobacco (BAT)||Vype, Chic, VIP, Ten Motives||glo, glo iFuse|
|Japan Tobacco International (JTI)||Logic, Ploom||Ploom Tech, Ploom Tech+, Ploom S|
|RJ Reynolds (owned by BAT)||Vuse||Revo,* Eclipse*|
For more information, please contact
Worrawan Jirathanapiwat, Tobacco Industry Denormalization Program Manager, Email: email@example.com
[i] Google Books. (2019). Public Health Consequences of E-Cigarettes. [online] Available at: https://bit.ly/2Xa0bvN.
[ii] U.S. Food and Drug Administration. (2019). Vaporizers, E-Cigarettes, and other ENDS. [online] Available at: https://bit.ly/2Qac3g4.
[iii] World Health Organization. (2019). Heated tobacco products (HTPs) information sheet. [online] Available at: https://bit.ly/2O2giY7.
[iv] World Health Organization. (2019). WHO Report on the Global Tobacco Epidemic, 2019. Geneva: World Health Organization
[v] Bursztynsky, J. (2019). Researchers find e-cigarettes cause lung cancer in mice in first study tying vaping to cancer. [online] CNBC. Available at: https://cnb.cx/2QaQZ9g.
[vi] Becker, R. (2019). Why Big Tobacco and Big Vape love comparing nicotine to caffeine. [online] Available at: https://bit.ly/2X4jPcC.
[vii] Mishra A, Chaturvedi P, Datta S, et al. (2015). Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology. DOI: 10.4103/0971-5851.151771
[viii] Goriounova, N. A., & Mansvelder, H. D. (2012). Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function. Cold Spring Harbor perspectives in medicine, 2(12), a012120. DOI:10.1101/cshperspect.a012120
[ix] Yuan, M., Cross, S. J., Loughlin, S. E., & Leslie, F. M. (2015). Nicotine and the adolescent brain. The Journal of physiology, 593(16), 3397–3412. DOI:10.1113/JP270492
[x] World Health Organization. (2014). Electronic nicotine delivery systems: Report by WHO [online] Available at: https://bit.ly/2K9HPFR.
[xi] National Academies of Sciences, Engineering, and Medicine. (2018). Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. DOI: https://doi.org/10.17226/24952.
[xii] Hess IMR, Lachireddy K, & Capon A. (2016). A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Res Pract 26(2):e2621617. DOI: http://dx.doi.org/10.17061/phrp2621617
[xiii] National Academies of Sciences, Engineering, and Medicine. (2018). Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. DOI: https://doi.org/10.17226/24952.
[xiv] Rapaport, L. (2019). Vaping may aid smoking cessation but also boost relapse risk. [online] U.S. Available at: https://reut.rs/2NEeiGQ.
[xv] Juul Labs. (2019). Juul Marketing & Social Media Code. https://www.juul.com/ourresponsibility# marketing-code.
[xvi] Siegel, D.A, et al. (2019). Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019.
[xvii] Sally Robertson, B. (2019). Vaping linked to over 200 health problems, but still safer than smoking. [online] News-Medical.net. Available at: https://bit.ly/34NNWYk [Accessed 11 Nov. 2019].
[xviii] Snaith, E. (2019). What are the dangers of vaping?. [online] The Independent. Available at: https://bit.ly/2O3K8LV.
[xix] Ridzaimi, S. (2019). M’sian Shares How Vaping Caused Tonsil & Tumour Growth, Had to Spend RM20k for Surgery – Southeast Asia Tobacco Control Alliance. [online] Seatca.org. Available at: https://bit.ly/2O6hnyj.
[xx] France-Presse, A. (2019). First Vaping Hospitalization Reported in Canada. [online] Voice of America. Available at: https://bit.ly/2CDITO4.
[xxi] Centers for Disease Control and Prevention. (2019). [online] Available at: https://bit.ly/32GHrFo.
[xxii] David G. Allan, C. (2019). How to convince, scare or bribe your kids not to vape. [online] CNN. Available at: https://cnn.it/2qL0rFk.
[xxiii] US Surgeon General. (2019) Know the Risks: E-cigarettes & Young people. Available at: https://bit.ly/33Iymxa.
[xxiv] Nytimes.com. (2019). E-Cigarettes Went Unchecked in 10 Years of Federal Inaction. [online] Available at: https://nyti.ms/2O0VXCM.
[xxv] Rogers, L. and Health, J. (2019). Vaping Q&A: Johns Hopkins Expert on E-Cigarettes and Tobacco Alternatives. [online] Johns Hopkins Bloomberg School of Public Health. Available at: https://bit.ly/2O6hE4j.
[xxvii] Chaykowski, K. (2019). The Disturbing Focus Of Juul’s Early Marketing Campaigns. [online] Forbes.com. Available at: https://bit.ly/2CCsJVw.
[xxviii] Rogers, L. and Health, J. (2019). Vaping Q&A: Johns Hopkins Expert on E-Cigarettes and Tobacco Alternatives. [online] Johns Hopkins Bloomberg School of Public Health. Available at: https://bit.ly/2O6hE4j.Q