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The risks of electronic cigarette use are uncertain. This is due to there being little data regarding their health effects and to the variability of vaporizers and variability in liquid ingredients and in their concentration and quality, and thus variability of the contents of mist delivered to the user. The limited evidence suggests that e-cigarettes are probably safer than traditional cigarettes. They are similar in toxicity to other nicotine replacement products, but there is not enough data to draw conclusions. The evidence suggests that the US Food and Drug Administration (FDA) accepted products such as a nicotine inhaler may be a safer way to give nicotine than e-cigarettes. A July 2014 World Health Organization (WHO) report cautioned about potential risks of using electronic cigarettes. The report concluded that "the existing evidence shows that ENDS aerosol is not merely "water vapour" as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses." A 2014 systematic review concluded that the risks of e-cigarettes have been exaggerated by health authorities and stated that it is apparent that there may be some remaining risk accompanied with e-cigarette use, though the risk of e-cigarette use is likely small compared to smoking tobacco. As of 2014, e-cigarettes cannot be regarded as harmless. Until additional data is available on the topic, using e-cigarettes cannot be regarded as safe. No long-term studies have shown that e-cigarettes are a "healthier alternative" to traditional cigarettes.

Toxicology

A preliminary analysis of e-cigarette cartridges by the US Food and Drug Administration (FDA) in 2009 identified that some contain tobacco-specific nitrosamines (TSNAs), known cancer-causing agents. The tobacco specific impurities suspected of being harmful to humans were anabasine, myosmine, and β-nicotyrine. They were detected in a majority of the samples. The amounts of TSNAs present were on par with a nicotine inhaler. The FDA's analysis also detected diethylene glycol, which is poisonous, in a single cartridge manufactured by Smoking Everywhere and nicotine in one cartridge claimed to be nicotine-free. This prompted the FDA to warn that e-cigarettes may present a health risk. While diethylene glycol was found in a cartridge tested in 2009 by the FDA, in 2011 researchers reviewed the data and noted that 15 other studies had failed to find any evidence of this chemical in e-cigarettes. The UK National Health Service noted that the toxic chemicals found by the FDA were at levels one-thousandth that of cigarette smoke, and that while there is no certainty that these small traces are harmless, initial test results are reassuring. Further concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device. They are similar in toxicity to other nicotine replacement products, but there is not enough data to draw conclusions. A 2014 review found that the "Levels of carcinogens and toxins in e-cigarettes typically exceeded those measured in an FDA-approved nicotine inhaler, suggesting that FDA-approved devices may be a safer method of nicotine delivery."

The distribution on the amount of nicotine inhaled by the user is not clear. Serum nicotine levels identified are inharmonious and rely upon the user and the device. There was inconsistent labeling of the actual nicotine content on e-liquid cartridges from some brands. Some nicotine has been found in ‘no nicotine' liquids. Due to nicotine content inconstancy, it is recommended that e-cigarette companies develop quality standards with respect to nicotine content. There are safety issues with the nicotine exposure from e-cigarettes, which has the possibility of causing addiction and other adverse effects. Serum cotinine levels are comparable to that of traditional cigarettes. The risk is probably low from the inhalation of propylene glycol and glycerol. If exposure of aerosols to propylene glycol and glycerin rises to levels that one would consider the exposure in association with a workplace setting, it would be sensible to investigate the health of exposed persons. The essential propylene glycol and/or glycerol mixture may consist of natural or artificial substances to provide it flavor. Some of these substances are regarded as toxic and a number of them resemble known carcinogens. Although the majority of aromatic substances that mimic tobacco and others using generally inaccurate terms such as ‘vegetable flavoring' are approved for human use, there are no studies in respect to the short- and long-term effects of the inhalation of these substances. There is a concern that some flavors could interest children.

A 2014 review found "Various chemical substances and ultrafine particles known to be toxic, carcinogenic and/or to cause respiratory and heart distress have been identified in e-cigarette aerosols, cartridges, refill liquids and environmental emissions." Many toxic chemical compounds have been produced from e-cigarettes, especially carbonyl compounds like formaldehyde, acetaldehyde, acrolein, and glyoxal, which are frequently identified in e-cigarette aerosols. These materials may cause harmful health effects; though, in the majority of cases, the amounts inhaled are less than those in traditional cigarettes. The toxicity of e-cigarettes and e-liquid can vary greatly, as there is potential differences in construction and materials in the delivery device, kind and origin of ingredients in the e-liquid, and the use or non-use of good manufacturing practices and quality control approaches. While there is variability in the ingredients and concentrations of ingredients in e-cigarette liquids, tobacco smoke contains thousands of chemicals, most of which are not understood and many of which are known to be harmful. The levels of chemical constituents in the mist were found to be 1 to 2 orders of magnitude smaller than in cigarette smoke but greater compared to a nicotine inhaler. The Centers for Disease Control and Prevention (CDC) stated the possible negative impact between nicotine and brain development in youth is a concern. A serious concern is the outcome of nicotine on the growing adolescent brain. There is no long-term research concerning the cancer risk related to the small level of exposure to the identified carcinogens. The short-term toxicity of e-cigarette use appears to be low, with the exception for some people with reactive airways. The long-term health impacts of e-cigarette use are unknown. The long-term toxicity is subject to the additives and contaminants in the e-liquid. There is limited peer-reviewed data about the toxicity of e-cigarettes for a complete toxicological evaluation.

A 2013 review found after using a single e-cigarette there was an instant increase in airways resistance and concluded that they can do harm to the respiratory system. The risks, especially to the lungs, are not fully understood and are of concern to public health authorities. The particles are of the ultrafine size similar to that of traditional cigarettes, and can go deep in the lungs and then into the systemic circulation. Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern. A 2014 review found e-cigarettes emissions contain the heavy metals nickel, tin, and chromium. These nanoparticles can deposit in the lung's alveolar sacs, potentially leading to local respiratory toxicity and entering the bloodstream. A 2014 review found it can be concluded that there is no evidence of contamination of the aerosol with metals that justifies a health concern. Another 2014 review found that the levels of metals were 10-50 times less than the point where they do harm. A 2014 review found that e-cigarettes used in the short-term on specified cardiovascular and respiratory functional results have demonstrated that even though some minor harmful effects of vaping are documented, these are appreciably milder in comparison to traditional cigarettes. When used in the short-term, an e-cigarette results in a rise of respiratory resistance comparatively to traditional cigarettes. The long-term effects regarding respiratory flow resistance are unknown. E-cigarette use can be associated with a substantial dispersion of nicotine, thus generating a plasma nicotine concentration which can be comparable to that of traditional cigarettes. This is due to the minute nicotine particles in the mist permit quick delivery into the bloodstream. This could explain the increased risk of cardiac arrhythmias and hypertension, which can affect some users, particularly those with atherosclerosis or other cardiovascular risk factors, to developing a significant risk of acute coronary syndrome. The limited evidence suggests that e-cigarettes produce less short-term effects on lung function than traditional cigarettes. Like cancer risk, there is no literature outlining the long-term lung function or cardiovascular consequences. A 2014 review found that e-cigarette aerosol contains far fewer carcinogens than tobacco smoke, and concluded that e-cigarettes "impart a lower potential disease burden" than traditional cigarettes. The affect on population health from e-cigarettes is unknown.

Environmental impact

There is limited information available on the environmental issues in connection with the production, the usage, and the disposing of e-cigarettes. As of 2014, it is uncertain if the nicotine in e-liquid is United States Pharmacopeia-grade nicotine, a tobacco extract, or a synthetic when examining the environmental impact of how its made. Some e-cigarette brands state their products are ‘eco-friendly’ or ‘green’, even though in the absence of any supporting studies. Some journalists contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors. It is unclear how many traditional cigarettes are comparable to using one e-cigarette for the average user. It is unclear in the manner that energy and materials used for production equate if e-cigarettes and traditional cigarettes are assessed on the basis of use. Even though some brands have began recycling services for their e-cigarette cartridges, the frequency of these services is unknown. Some brands have also began recycling services for their e-cigarette batteries. The frequency of recycling information on expendable e-cigarette finished product containers, along with how often expendable e-cigarettes are recycled, is unknown.

Ultrafine particles

E-cigarettes produce particles, in the form of an aerosol. The aerosol produced from an e-cigarette is frequently but inaccurately called vapor. Technically, a vapor is a substance in the gas phase whereas an aerosol (mist) is a suspension of tiny particles of liquid, solid or both within a gas. The word "vaping" is not technically accurate when applied to e-cigarettes. The aerosol is made-up of liquid sub-micron particles of condensed vapor; thus, the users of these devices are rather "aerosolizing." The e-cigarette mist resembles cigarette smoke. A 2014 review found "Following a puff, the aerosol is delivered into the user's mouth and lungs by inhalation, after which the remaining aerosol is exhaled into the environment." E-cigarettes provide nicotine by creating liquid particles, a mist. E-cigarette mist mostly consist of propylene glycol, glycerol, water, flavorings, nicotine, and chemicals.

Fine particles can be chemically intricate and not uniform, and what a particle is made of, the exact harmful elements, and the importance of the size of the particle is mostly unknown. Because these things are uncertain, it is not clear whether the particles in e-cigarette mist have health effects similar to those produced by traditional cigarettes. The nature and chemical composition of particles in e-cigarette mist is entirely distinct from those in cigarette smoke. Though, the particle size distribution and sum of particles emitted by e-cigarettes are like traditional cigarettes, with the majority of particles in the ultrafine range (modes, ≈100–200 nm).

Adverse effects

E-cigarettes use lithium batteries most of the time; improper use may result in accidents. Rare major injuries have occurred from battery malfunctions such as explosions and fires. The explosions resulted either by extended charging and use of unsuitable chargers or by design flaws have occurred. It is recommended manufacturing quality standards be employed in order to prevent such accidents. Some of the risks from e-cigarette use could probably be reduced by better product design and standards. Use-related concerns with e-liquids involve leaks or spills and contact with contaminants in the e-liquid.

Less serious adverse effects of throat and mouth inflammation, vomiting, nausea, and cough have resulted from e-cigarette use. Short-term adverse effects include mouth and throat inflammation, dry cough, and nausea. Adverse effect are mostly associated with short-term of use. Long-term studies regarding the effects of e-cigarettes after chronic exposure are unavailable. In youth, e-cigarette use risks involve accidental nicotine exposure and are possible choking dangers in youth. In pediatric patients, accidental exposures include ingesting of e-liquids and inhaling of e-cigarette mists. The US Food and Drug Administration Center for Tobacco Products reported between 2008 and the beginning of 2012, 47 cases of adverse effects associated with e-cigarettes, and eight were considered serious. A causal relationship between e-cigarettes and the reported adverse effects was not established with the exception of two severe outcomes in the United States: a death when an infant choked on the cartridges and burns when one blew up.

In the United States the number of calls to poison control centers related to electronic cigarettes have increased between 2010 and 2014 such that they now represent 42% of reported cases due to either cigarettes and e-cigarettes up from 0.3%. These calls were in connection to both adults and children. E-cigarettes were associated with fewer adverse effects than nicotine patches. Calls to U.S. poison control centers related to e-cigarette exposures were inhalations, eye exposures, skin exposures, and ingestion, which included adults and young children. The California Poison Control System reported from 2010 to 2012, 35 cases of e-cigarette contact. 14 were from children and 25 were from accidental contact. The majority of adverse effects reported were nausea, vomiting, dizziness and oral irritation.

Mist

Since e-cigarettes do not burn (or contain) tobacco, no side-stream smoke or any cigarette smoke is produced. Only what is exhaled by electronic cigarettes users enters the surrounding air. E-cigarettes used in indoor environments can put at risk nonsmokers to elevated levels of nicotine and aerosol emissions. A 2014 review of limited data concluded this mist can cause indoor air pollution and is not just "water vapor" as is frequently stated in the advertising of e-cigarettes. Exhaled mist consists of nicotine and some other particles, primarily consisting of flavors, aroma transporters, glycerol and propylene glycol. Bystanders are exposed to these particles from exhaled e-cigarette mist. A mixture of harmful substances, particularly nicotine, ultrafine particles, and volatile organic compounds can be exhaled into the air. The dense mist consists of liquid sub-micron droplets. The liquid particles condenses into a viewable fog. The mist is in the air for a short time, with a half-life of about 10 seconds; traditional cigarette smoke is in the air 100 times longer. This is because of fast revaporization at room temperature. Some of the few studies examining the effects on health shown that being exposed to e-cigarette mist may produce biological effects. Since e-cigarettes have not been widely used long enough for evaluation, the long-term health effects from the second-hand mist are not known.

As of 2013, the only clinical study currently published evaluating the respiratory effects of passive vaping found no adverse effects were detected. A 2014 review found it is safe to infer that their effects on bystanders are minimal in comparison to traditional cigarettes. A 2014 WHO report stated passive exposure was as a concern, indicating that current evidence is insufficient to determine whether the levels of exhaled mist are safe to involuntarily exposed bystanders. The report concluded that the aerosol emissions are likely to increase the risk of disease to nearby bystanders, especially from those e-cigarettes which produce toxicant levels close to those emitted by certain cigarettes. E-cigarette mist has notably fewer toxicants than cigarette smoke (other than particulates) and is likely to pose less harm to users or bystanders.

Nonsmokers exposed to e-cigarette aerosol produced by a machine and pumped into a room were found to have detectable levels of the nicotine metabolite cotinine in their blood. The same study stated that 80% of nicotine is normally absorbed by the user, so these results may be higher than in actual second hand exposure. A 2014 review stated there are concerns about pregnant women exposure to e-cigarette mist through direct use or via exhaled mist. As of 2014, there is no conclusions on the possible hazards of pregnant women using e-cigarettes, and there is a developing research on the negative effects of nicotine on prenatal brain development. A 2014 review concluded no amount of nicotine is safe for pregnant women. As of 2014, the long-term issues of e-cigarettes on both mother and unborn baby are unknown. There are concerns about the health impacts of pediatric exposure to second-hand and third-hand e-cigarette mists.

There is insufficient data to determine the impact on public health of e-cigarettes. A white paper published in 2014 by the American Industrial Hygiene Association concluded e-cigarettes emit airborne contaminants that may be inhaled by the user and those nearby. Due to this possible risk, they urged restriction of their use indoors, similar to smoking bans, until research has shown the aerosol does not significantly harm others in the area. A 2014 review indicated that the levels of inhaled contaminants from the e-cigarette mist are not of significant health concern for human exposures by the standards used in workplaces to ensure safety.

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External links

• Media related to Electronic cigarettes at Wikimedia Commons

• Cigarette types
• Technology
• Chinese inventions
• Smoking cessation
• 2003 introductions