What are the public health impacts of e-cigarettes?

What are the public health impacts of e-cigarettes?

Despite the fact that traditional cigarette consumption has been on the decline in the United States since the mid-1970s1, the use of electronic cigarettes, or “e-cigarettes,” among adults and teenagers is becoming more and more prevalent. These devices are regularly marketed as a safe alternative to smoking conventional cigarettes, and are promoted as smoking cessation aids, similar to nicotine patches and nicotine gum. However,  e-cigarettes are becoming increasingly scrutinized by health experts and regulatory agencies and there are an increasing number of questions surrounding these safety claims, particularly in regard to exposure among teenagers and young children. This article explains the known and anticipated risks of e-cigarette use, as well as the potential for accidental ingestion of liquid nicotine by small children.

What are e-cigarettes, and how are they different from regular cigarettes?

Smoking (or “vaping”) with an e-cigarette creates an inhalable form of nicotine that the user can breathe in, just like a normal cigarette. In fact, many e-cigarettes are designed to look just like a regular cigarette, cigar, or pipe. However, one big difference between an e-cigarette and a regular cigarette is that an e-cigarette does not contain tobacco. Instead, an e-cigarette contains a compact, battery-powered device that heats a replaceable cartridge containing a liquid mixture. The liquid mixture is vaporized by an anodizing device, and delivered to the user as an inhalable vapor.

The liquid mixture in the cartridge usually contains nicotine, which is the highly addictive drug that is also present in traditional tobacco products. Therefore, an e-cigarette is designed to deliver a dose of nicotine to the user, while greatly reducing or eliminating exposure to many (albeit not all) of the other harmful substances that are present in traditional tobacco products.

Why are teenagers using e-cigarettes more frequently?

E-cigarette use is becoming more popular among teenagers, so it’s important for parents to understand how their use may be harmful to children. According to a Centers for Disease Control and Prevention (CDC) study using data from the 2012 National Youth Tobacco Survey2, during the period from 2011 – 2012, e-cigarette use doubled among middle school females, high school females, and middle school males, and increased more than 60% among high school males. This increase was attributed, in part, to increased availability and marketing of e-cigarettes, as well as the perception amongst young adults that the devices are safer than traditional cigarettes and other tobacco products.

Furthermore, the liquid nicotine used in e-cigarettes very often contains flavoring additives and other sweeteners. This type of marketing can convince young adults to try e-cigarettes for the first time, which can lead to nicotine addiction. There is currently a debate among health experts as to whether e-cigarettes may be considered a “gateway drug” and encourage children and young adults to also experiment with traditional tobacco products and marijuana. A recent study3 published in the Journal of the American Medical Association reviewed survey data from nearly 40,000 US middle and high school students, and found that adolescents who use e-cigarettes are more likely to smoke conventional cigarettes.  Further study is clearly warranted to comprehensively address the “gateway drug” concern.

What are the toxicity concerns associated with e-cigarettes?

A laboratory analysis was conducted on samples of e-cigarettes by the U.S. Food and Drug Administration (FDA) in 20094. Several findings raised concern regarding the safety of e-cigarettes. The liquid mixture added to e-cigarette cartridges contained detectable concentrations of several chemicals, including nitrosamines, anabasine, myosmine, beta-nicotyrine, and diethylene glycol, all of which are known to be toxic to humans. Furthermore, although many e-cigarette liquid cartridges are labeled as containing low amounts of nicotine, the FDA analysis found that the actual amount of nicotine contained within the “e-liquid” or “liquid nicotine” used to fill the e-cigarette cartridges was highly variable and unpredictable compared to the level of nicotine specified on the labels of liquid nicotine bottles. There are currently no safeguards or quality controls in place to confirm that the level of nicotine advertised on the label of a liquid nicotine bottle is the actual amount present.

The FDA has stated its intention to regulate e-cigarettes, which would include banning the sale of e-cigarettes to children under 18, requiring manufacturers to register with the FDA so they can be monitored for safety and quality, and further requiring manufacturers to substantiate marketing claims using scientific evidence. However, this regulatory action is only in its initial stages, so these products are effectively unregulated and manufacturers may market them to individuals of any age. Further details can be found on the FDA website at: http://www.fda.gov/TobaccoProducts/Labeling/ucm388395.htm.

Perhaps even more concerning is a noticeable increase in the frequency of accidental exposure to the e-cigarette cartridge liquid among young children. The CDC analyzed data on e-cigarette related calls to U.S. poison control centers from September 2010 through February 20145, and found that e-cigarette exposure calls increased on a per month basis from one call in September 2010 to 215 calls in February 2014. Approximately 51% of these calls related to accidental exposure to children of less than six years of age, and 68.9% of the calls were related to accidental ingestion of the liquid mixture. Ingestion of nicotine at high doses can lead to nausea, rapid heart rate, and perspiration, followed by a slowing of the heart rate with a fall in blood pressure6. At very high concentrations, nicotine can cause paralysis of the muscles that control breathing6, which can lead to death. Exposure via contact with the skin is also of concern, which can cause irritation, redness, or an allergic reaction in addition to the symptoms listed above, due to absorption of nicotine from the surface of the skin into the bloodstream6.

How can we reduce exposure to e-cigarettes among children?

It is important to remember that the safety claims being made by e-cigarette manufacturers have not been validated by any scientific or regulatory body, and that there have been serious questions raised in regard to the marketing of these products to children and teenagers, the potential of e-cigarettes to serve as a “gateway drug” among teenagers, and the demonstrated toxicity of the liquid nicotine mixture in young children following accidental exposure through ingestion and/or the skin.

Parents can encourage their children to avoid e-cigarette use by talking to them about the dangers of smoking in general, and including e-cigarettes in an overall discussion of avoiding cigarette and tobacco use. Parents should also consider avoiding use of e-cigarettes and instead use FDA recommended products for smoking cessation such as nicotine patches and nicotine gum. Parents can comment on the FDA’s proposed legislation on e-cigarettes by visiting this website: http://www.regulations.gov/#!documentDetail;D=FDA-2014-N-0189-0001.

If e-cigarettes are used in your household, extreme care must be exercised in keeping the e-cigarette cartridges and the liquid nicotine refills safely stored out of the reach of young children to prevent accidental exposure.   If your children accidentally ingest or their skin comes into contact with liquid nicotine, call your local poison control center immediately.


Written by NSF



1The American Lung Association, Research and Program Services, Epidemiology and Statistics Unit. Trends in Tobacco Use. July 2011.

2Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR). Tobacco Product Use Among Middle and High School Students – United States, 2011 and 2012. November 15, 2013, 62(45);893-897.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm Accessed: May 16, 2014.


3Dutra LM and Stanton AG. Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents: A Cross-sectional Study. JAMA Pediatr. Published onlineMarch 6, 2014.

4Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA.

http://www.fda.gov/newsevents/publichealthfocus/ucm173146.htm Accessed: April 3, 2014.


5Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR). Notes from the Field: Calls to Poison Control Centers for Exposures to Electronic Cigarettes – United States, September 2010 – February 2014. April 4, 2014, 63(13);292-293.


6Centers for Disease Control and Prevention (CDC). The Emergency Response Safety and Health Database (Entry for Nicotine). http://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750028.html Accessed: May 28, 2014.



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