Electronic cigarette: Difference between revisions - Wikipedia

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The benefits and risks of electronic cigarette use are uncertain.<ref name=Odum2012/><ref name=Harrell2014/> Evidence suggests e-cigarettes may be safer than smoking tobacco products.<ref name=NHE2014>{{citation|url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf|title=Electronic cigarettes – A report commissioned by Public Health England |publisher=[[Public Health England]]|date=15 May 2014|author1-first=John |author1-last=Britton|author2-first=Ilze|author2-last=Bogdanovica}}</ref><ref name=Caponnetto2013/> To encourage e-cigarette use as a harm reduction and cessation aid in cigarette users is premature.<ref name=Drummond2014/> They may possibly be as safe as other [[nicotine replacement products]], but there is not enough data to draw conclusions.<ref name=NHE2014/><ref name=Caponnetto2013/> They may carry a risk of addiction in those who do not already smoke,<ref name="WHOJuly2013">{{cite web|title=Tobacco Free Initiative (TFI)|url=https://web.archive.org/web/20130721131331/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en|website=World Health Organization|date=9 July 2013}}</ref> but there is no evidence of ongoing use among those who have never smoked.<ref name=Haj2014/> They may promote delaying or deterring to [[quit smoking]].<ref name=Grana2014/> Emissions from e-cigarette may contain flavors, aroma transporters, glycerol, propylene glycol, nicotine, tiny amounts of carcinogens and heavy metals, and other chemicals, in the form of [[ultrafine particle|tiny particles]].<ref name=Grana2014/><ref name=Haj2014/> The evidence indicates the levels of contaminants do not warrant health concerns according to workplace safety standards.<ref name=Bur2014/> E-cigarette mist has fewer toxicants than cigarette smoke.<ref name=Grana2014/> They are likely to be less harmful to users and bystanders.<ref name=Grana2014/><ref name=Haj2014/> Less serious [[adverse effect|complaints]] from e-cigarette users include throat and mouth inflammation, vomiting, nausea, and cough.<ref name=Grana2014/>

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=== Harm reduction ===

A 2014 review found the harm to users and bystanders from long-term use of e-cigarettes compared to tobacco cigarettes could be less, to possibly none.<ref name=Haj2014/> A 2014 review found some evidence exists that e-cigarettes may help lower tobacco cigarette use, however no long-term studies have been done on e-cigarettes safety.<ref name=Drummond2014/> Therefore, their role in [[tobacco harm reduction]] as a substitute for tobacco products is unclear.<ref name=Drummond2014>{{cite journal|last1=Drummond|first1=MB|last2=Upson|first2=D|title=Electronic cigarettes. Potential harms and benefits.|journal=Annals of the American Thoracic Society|date=February 2014|volume=11|issue=2|pages=236–42|pmid=24575993}}</ref>

[[Tobacco harm reduction]] has been a controversial area of tobacco control.<ref name=Cahn2011>{{cite journal |last1= M. |first1=Z. |last2=Siegel |title=Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? |journal=Journal of public health policy |date=February 2011 |volume=32 |issue=1 |pages=16–31 |pmid=21150942 |doi= 10.1057/jphp.2010.41 |first2= M}}</ref> The health community have been cautious to support the [[tobacco industry]] to bring safer products to market that will lessen the risks related with tobacco use.<ref name=Cahn2011/> A 20112014 review found in the fightharm againstto decreaseusers tobaccoand relatedbystanders deathfrom andlong-term disease,use of e-cigarettes showcompared greatto promise.<ref name=Cahn2011/> Adults most often use electronictobacco cigarettes ascould abe replacement for tobaccoless, althoughto notpossibly always to quitnone.<ref name=Car2014Haj2014/> AlthoughA some2014 peoplereview havefound asome desireevidence toexists quit smoking by usingthat e-cigarettes, othermay commonhelp explanationslower fortobacco thecigarette use, ofhowever theseno productslong-term arestudies tohave reducebeen harmdone fromon smokinge-cigarettes safety.<ref name=BrittonBogdanovica2014Drummond2014/>{{cite web |title=Electronic Cigarettes |author=BrittonTherefore, J.their &role Bogdanovica,in I.|url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdftobacco |publisher=Publicharm Healthreduction Englandas |date=Maya 2014substitute |accessdate=21for Maytobacco 2014}}</ref>products andis to cut back on traditional cigarettesunclear.<ref name=Grana2014Drummond2014>{{cite journal|lastlast1=GranaDrummond|firstfirst1=RMB|author2last2=Benowitz, N Upson|author3first2=Glantz, SA D|title=E-Electronic cigarettes:. aPotential scientificharms reviewand benefits.|journal=CirculationAnnals of the American Thoracic Society|date=13 MayFebruary 2014|volume=12911|issue=192|pages=1972–86236–42|pmid=24821826|doi=10.1161/circulationaha.114.00766724575993}}</ref> Smoke from traditional tobacco products has 40 known carcinogens among the 10,000 chemicals it contains, none of which has been found in more than trace quantities in the cartridges or mist of e-cigarettes.<ref name=Cahn2011/> A 2011 review stated that while e-cigarettes can not be considered "safe" because there is no safe level for carcinogens, they are doubtless safer compared to tobacco cigarettes.<ref name=Cahn2011/> Any residual risk of e-cigarette use should be weighed relative to the risk of continuing or returning to smoking, taking account of the low success rate of currently-approved smoking cessation medications.<ref name=FarsalinosPolosa2014/> A 2014 review argued that regulations for electronic cigarettes should be similar to those for dietary supplements or cosmetic products to not limit the potential for harm reduction with electronic cigarettes replacing tobacco.<ref name=Saitta2014>{{cite journal|last=Saitta|first=D|author2=Ferro, GA |author3=Polosa, R |title=Achieving appropriate regulations for electronic cigarettes.|journal=Therapeutic advances in chronic disease|date=Mar 2014|volume=5|issue=2|pages=50–61|pmid=24587890|doi=10.1177/2040622314521271}}</ref> A 2011 review found in the fight against decrease tobacco related death and disease, e-cigarettes show great promise.<ref name=Cahn2011/>

Adults most often use electronic cigarettes as a replacement for tobacco, although not always to quit.<ref name=Car2014/> Although some people have a desire to quit smoking by using e-cigarettes, other common explanations for the use of these products are to reduce harm from smoking<ref name=BrittonBogdanovica2014>{{cite web |title=Electronic Cigarettes |author=Britton, J. & Bogdanovica, I.|url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf |publisher=Public Health England |date=May 2014 |accessdate=21 May 2014}}</ref> and to cut back on traditional cigarettes.<ref name=Grana2014>{{cite journal|last=Grana|first=R|author2=Benowitz, N |author3=Glantz, SA |title=E-cigarettes: a scientific review.|journal=Circulation|date=13 May 2014|volume=129|issue=19|pages=1972–86|pmid=24821826|doi=10.1161/circulationaha.114.007667}}</ref> Smoke from traditional tobacco products has 40 known carcinogens among the 10,000 chemicals it contains, none of which has been found in more than trace quantities in the cartridges or mist of e-cigarettes.<ref name=Cahn2011/> A 2011 review stated that while e-cigarettes can not be considered "safe" because there is no safe level for carcinogens, they are doubtless safer compared to tobacco cigarettes.<ref name=Cahn2011/> Any residual risk of e-cigarette use should be weighed relative to the risk of continuing or returning to smoking, taking account of the low success rate of currently-approved smoking cessation medications.<ref name=FarsalinosPolosa2014/>

In 2014 a report commissioned by [[Public Health England]] concluded that there is large potential for health benefits when switching from tobacco use to other nicotine delivery devices such as electronic cigarettes, but realizing their full potential requires regulation and monitoring to minimize possible risks.<ref name="NHE2014" /> The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.<ref name="BMA handout">{{cite web|title=BMA calls for stronger regulation of e-cigarettes|url=http://bma.org.uk/-/media/Files/PDFs/Working%20for%20change/Improving%20health/tobaccoecigarettespublicplaces_jan2013.pdf|publisher=British Medical Association|accessdate=18 November 2013}}</ref> The [[American Association of Public Health Physicians]] (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and [[smokeless tobacco]] for long term use instead of smoking.<ref>{{cite web |title=Principles to Guide AAPHP Tobacco Policy |url=http://www.aaphp.org/tobacco|work=American Association of Public Health Physicians |accessdate=31 July 2013}}</ref> A 2012 review found electronic systems appear to generally deliver less nicotine than smoking, raising the question of whether they can effectively substitute for tobacco smoking over a long-term period.<ref name=O2012/> In an interview, the director of the Office on Smoking and Health for the U.S. federal agency [[Centers for Disease Control and Prevention]] (CDC) believes that there is enough evidence to say that using e-cigarettes is likely less harmful than smoking a pack of conventional cigarettes.<!-- <ref name=CDCQ&A/> --> However, due to the lack of regulation of the contents of the numerous different brands of electronic cigarettes and the presence of nicotine, which is not a benign substance, the CDC has issued warnings.<ref name=CDCQ&A/> A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both tobacco cigarettes and electronic cigarettes.<!-- <ref name="WHO Position 2014" /> --> This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."<ref name="WHO Position 2014" />

=== Safety ===

The risks of electronic cigarette use are uncertain.<ref name="Odum2012">{{cite journal|last1=Odum|first1=L. E.|last2=O'Dell|first2=K. A.|last3=Schepers|first3=J. S.|title=Electronic cigarettes: do they have a role in smoking cessation?|journal=Journal of pharmacy practice|date=December 2012|volume=25|issue=6|pages=611–4|pmid=22797832|doi=10.1177/0897190012451909}}</ref><ref name=Harrell2014/> This is due to there being little data regarding their health effects<ref name="Palazzolo">{{Citation | title=Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review. | url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859972/ | author1-first=Dominic L. |author1-last=Palazzolo | journal=Frontiers in Public Health | volume=1 |issue=56 | date=Nov 2013| doi=10.3389/fpubh.2013.00056 | pmid=24350225 | pmc=3859972}}</ref> 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.<ref name="Grana2014" /><ref name="Odum2012" /><ref name="O2012">{{cite journal|last=O'Connor|first=RJ|title=Non-cigarette tobacco products: what have we learnt and where are we headed?|journal=Tobacco control|date=March 2012|volume=21|issue=2|pages=181–90|pmid=22345243|doi=10.1136/tobaccocontrol-2011-050281|pmc=3716250}}</ref><ref name=CDCQ&A>{{cite web |author=Edgar, Julie |title=E-Cigarettes: Expert Q&A With the CDC |url=http://www.webmd.com/smoking-cessation/news/20131112/e-cigarettes-cdc |publisher=WebMD |accessdate=17 November 2013}}</ref><ref name="FDAPublicHealthFocus">{{cite web|title=Public Health Focus: Electronic Cigarettes (e-Cigarettes)|url=http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm|publisher=FDA|date=24 April 2014}}</ref> However, some evidence suggests e-cigarettes may be safer than smoking tobacco products, and possibly as safe as other [[nicotine replacement products]] but there is insufficient data to draw conclusions.<ref name=Grana2014/><ref name="O2012" /> A July 2014 WHO report cautioned about potential risks of using electronic cigarettes.<ref name="WHO Position 2014"/> 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.<ref name=FarsalinosPolosa2014/><!-- Toxicology evidence -->

==== Toxicology ====

<!-- Toxicology evidence -->

[[File:Toxicants emitted by tobacco cigarettes and e-cigarettes ehp.122-A244.t001.png|thumbnail|left|Chart showing various toxicants as measured in cigarette and e-cigarette smoke.<ref>{{cite journal|last1=Arnold|first1=Carrie|title=Vaping and Health: What Do We Know about E-Cigarettes?|journal=Environmental Health Perspectives|volume=122|issue=9|year=2014|pages=A244–A249|doi=10.1289/ehp.122-A244|pmc=4154203|pmid=25181730}}</ref>]]

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.<ref name=FDA_nitrosamines>{{cite web|title=Safety Watch: Electronic Cigarettes|url=http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm173327.htm|publisher=FDA}}</ref> 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.<ref name="FDA Chemical Analysis">{{cite web|url=http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm|author=FDA|title=Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA|date=22 July 2009|accessdate=22 July 2009}}</ref> The amounts of TSNAs present were on par with existing NRT products like nicotine gum and inhalers. 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.<ref name=FDA_nitrosamines/><ref name="FDA Study"/> 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.<ref>{{cite web | url=http://www.ibtimes.com/e-cigarettes-effective-nicotine-patches-helping-smokers-quit-study-1403523 | title=E-Cigarettes As Effective As Nicotine Patches in Helping Smokers Quit: Study | work=[[International Business Times]] | date=8 September 2013 | accessdate=15 December 2013 | author=Palmer, Roxanne}}</ref> 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.<ref name=nhs>{{cite web|title=E-cigarettes to be regulated as medicines |publisher=[[National Health Service]]|date=12 June 2013|accessdate=August 2013|url=http://www.nhs.uk/news/2013/06June/Pages/e-cigarettes-and-vaping.aspx}}</ref> The risks, especially to the lungs, are not fully understood and are of concern to public health authorities and some reviewers.<ref name="NHE2014"/><ref name="WHO2013">{{cite web|title=Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems|url=http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html|work=World Health Organization|date=3 June 2014}}</ref><ref name=IUATLD>{{cite web |title=Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS] |url=http://www.theunion.org/what-we-do/publications/official/body/E-cigarette_statement_FULL.pdf |format=PDF |date=October 2013 |publisher=The International Union against Tuberculosis and Lung Disease}}</ref> Further concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device.<ref name="FDA Study">{{cite web|url=http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf|author=FDA|title=FDA 2009 Study Data: Evaluation of e-cigarettes|work=Food and Drug Administration (US) -center for drug evaluation and research|date=4 May 2009|accessdate=4 May 2009}}</ref> The risk is probably low from the inhalation of [[propylene glycol]] and [[glycerol]].<ref name=Haj2014/> The composition of inhaled levels of nicotine is not clear.<ref name=Drummond2014/> 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.<ref name=Saitta2014/> A 2014 review stated the [[ultrafine particle|particles are of the ultrafine size]] similar to cigarettes, and go deep in the lungs and then into the [[systemic circulation]].<ref name=Grana2014/> The levels of chemical compounds 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]].<ref name=Grana2014/> Reports in the literature have shown respiratory and cardiovascular effects by these smaller size particles, suggesting a possible health concern.<ref name=AIHA2014/> A 2014 review found e-cigarettes emissions contain the [[heavy metals]] nickel, tin, and chromium.<ref name=Grana2014/> These [[nanoparticle]]s can deposit in the [[pulmonary alveoli|lung's alveolar sacs]], potentially leading to local respiratory toxicity and entering the bloodstream.<ref name=Grana2014/> 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.<ref name=Bur2014/> Another 2014 review found that the levels of metals were 10-50 times less than the point where they do harm.<ref name=Haj2014/> 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.<ref name=FarsalinosPolosa2014/> The [[Centers for Disease Control and Prevention]] (CDC) stated the possible negative impact between nicotine and [[brain development]] in youth is a concern.<ref name=MMWR2013/> A serious concern is the outcome of nicotine on the growing adolescent brain.<ref name=CDCQ&A/> There is no long-term research concerning the cancer risk related to the small level of exposure to the identified carcinogens.<ref name=Drummond2014/> Like cancer risk, there is no literature outlining the long-term lung function or cardiovascular consequences.<ref name=Drummond2014/> The long-term [[health effect|health impacts]] of e-cigarettes use are unknown.<ref name=Haj2014/>

==== Adverse effects ====

<!-- Particle size -->

Fine particles can be chemically intricate, and the harmful elements and the importance of the size of the particle and what the particle is made of is mostly unknown, thus it is not clear whether the particles in e-cigarette emissions have health effects similar to those produced by traditional cigarettes.<ref name=Grana2014/>

<!-- Adverse effects -->

E-cigarettes use [[lithium batteries]] most of the time, improper use may result in accidents.<ref name=FarsalinosPolosa2014/> Rare major injuries have occurred from battery malfunctions such as explosions and fires.<ref name=Grana2014/> The explosions resulted either by extended charging and use of unsuitable chargers or by design flaws have occurred.<ref name=FarsalinosPolosa2014/> It is recommended manufacturing quality standards be employed in order to prevent such accidents.<ref name=FarsalinosPolosa2014/> Complaints of less serious [[adverse effect]]s of throat and mouth inflammation, vomiting, nausea, cough have resulted from e-cigarette use.<ref name=Grana2014/> In [[pediatric]] patients, accidental exposures include ingesting of e-liquids and inhaling of e-cigarette mists.<ref name="Durmowicz2014/">{{cite journal|last1=Durmowicz|first1=E-cigarette. useL.|title=The risksimpact involveof accidentalelectronic nicotinecigarettes exposureon andthe arepaediatric possiblepopulation|journal=Tobacco choking dangersControl|volume=23|issue=Supplement in youth2|year=2014|pages=ii41–ii46|issn=0964-4563|doi=10.<ref name1136/tobaccocontrol-2013-051468|pmid=Durmowicz201424732163}}</ref> The US [[Regulation of tobacco by the U.S. Food and Drug Administration#Center for Tobacco Products|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.<ref name=Haj2014/> 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.<ref name=Haj2014/>

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%.<ref name=Orr2014/> These calls were in connection to both adults and children.<ref name=Orr2014>{{cite journal|last1=Orr|first1=KK|last2=Asal|first2=NJ|title=Efficacy of Electronic Cigarettes for Smoking Cessation.|journal=The Annals of pharmacotherapy|date=November 2014|volume=48|issue=11|pages=1502–1506|pmid=25136064}}</ref> E-cigarettes were associated with fewer adverse effects than nicotine patches.<ref name=Orr2014/> Calls to U.S. [[poison control center]]s related to e-cigarette exposures were inhalations, eye exposures, skin exposures, and ingestion, which included adults and young children.<ref name=MMWR2014>{{cite journal |title=Notes from the field: calls to poison centers for exposures to electronic cigarettes--United States, September 2010-February 2014 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=63 |issue=13 |pages=292–3 |date=April 2014 |pmid=24699766 |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm |author1= Centers for Disease Control and Prevention (CDC)}}</ref> The California Poison Control System reported from 2010 to 2012, 35 cases of e-cigarette contact.<ref name=FarsalinosPolosa2014/> 14 were from children and 25 were from accidental contact.<ref name=FarsalinosPolosa2014/> The majority of adverse effects reported were nausea, vomiting, dizziness and oral irritation.<ref name=FarsalinosPolosa2014>{{cite journal|last1=Farsalinos|first1=K. E.|last2=Polosa|first2=R.|title=Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review|journal=Therapeutic Advances in Drug Safety|volume=5|issue=2|year=2014|pages=67–86|issn=2042-0986|doi=10.1177/2042098614524430|pmid=25083263}}</ref>

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<!-- Definition and Particle distribution -->

[[File:Cigarrillo electronico funcionando.jpg|thumb|Mist exhaled by a first generation e-cigarette user.]]

EThere are concerns about the health impacts oE-cigarettes produce particles suspended in a gas, in the form of a [[aerosol|mist]] that contains nicotine.<ref name=Grana2014/><ref name=Cheng2014/> Mist produced from an e-cigarette is frequently but inaccurately called [[vapor]].<ref name=Cheng2014/> Technically, a vapor is a substance in the gas phase whereas a mist/aerosol is a suspension of tiny particles of liquid, solid or both within a gas.<ref name=Cheng2014>{{cite journal|last1=Cheng|first1=T.|title=Chemical evaluation of electronic cigarettes|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii11–ii17|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051482|pmc=3995255|pmid=24732157}}</ref> A 2014 [[ASHRAE]] publication stated the word "vaping" is not technically accurate when applied to e-cigarettes and concluded that users of these devices are rather "aerosolizing."<ref name=Offermann2014>{{cite journal|last1=Offermann|first1=Francis|title=The Hazards of E-Cigarettes|journal=ASHRAE Journal|date=June 2014|volume=56|issue=6|url=http://www.gocolumbiamo.com/Health/Documents/Offermann-Thehazardsofe-cigarettes.pdf}}</ref> The nature and chemical composition of particles in e-cigarette mist is entirely distinct from those in cigarette smoke.<ref name=FarsalinosPolosa2014/> Though, the particle size composition and sum of particles emitted by e-cigarettes are like traditional cigarettes, with the majority of particles in the ultrafine range.<ref name=Grana2014/>

<!-- Emissions -->

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{{Asof|2013}}, the only clinical study currently published evaluating the respiratory effects of passive vaping found no adverse effects were detected.<ref name=FarsalinosPolosa2014/> A 2014 review found it is safe to infer that their effects on bystanders are minimal in comparison to traditional cigarettes.<ref name=FarsalinosPolosa2014/> 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.<ref name="WHO Position 2014"/> 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.<ref name="WHO Position 2014"/> E-cigarette mist has notably fewer toxicants than cigarette smoke (other than particulates) and is likely to pose less harm to users or bystanders.<ref name=Grana2014/><ref name=Saitta2014/><ref name=McRobbie2014>Hayden McRobbie, National Centre for Smoking Cessation and Training, 2014. [http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf Electronic cigarettes]</ref>

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.<!-- <ref name=Grana2014/> --> 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.<!-- <ref name=Grana2014/> --> A 2014 review stated there are concerns about pregnant women exposure to e-cigarette mist through direct use or via exhaled mist.<ref name=Grana2014/> {{Asof|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.<ref name=Drummond2014/> A 2014 review concluded no amount of nicotine is safe for pregnant women.<ref name=Suter2014/> {{Asof|2014}}, the long-term issues of e-cigarettes on both mother and unborn baby are unknown.<ref name=Suter2014>{{cite journal|last1=Suter|first1=Melissa A.|last2=Mastrobattista|first2=Joan|last3=Sachs|first3=Maike|last4=Aagaard|first4=Kjersti|title=Is There Evidence for Potential Harm of Electronic Cigarette Use in Pregnancy?|journal=Birth Defects Research Part A: Clinical and Molecular Teratology|year=2014|pages=n/a–n/a|issn=15420752|doi=10.1002/bdra.23333|pmid=25366492}}</ref> There are concerns about the health impacts of pediatric exposure to second-hand and third-hand e-cigarette mists.<ref name=Durmowicz2014/>

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.<ref name=AIHA2014/> 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.<ref name=AIHA2014>{{cite web|title=White Paper: Electronic Cigarettes in the Indoor Environment|url=http://tobacco.ucsf.edu/sites/tobacco.ucsf.edu/files/u9/AIHA-Electronc%20Cig%20Document_Final.pdf|publisher=American Industrial Hygiene Association|date=October 19, 2014}}</ref> 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.<ref name=Bur2014>{{cite journal|last1=Burstyn|first1=I|title=Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks.|journal=BMC Public Health|date=9 January 2014|volume=14|pages=18|pmid=24406205|doi=10.1186/1471-2458-14-18|pmc=3937158}}</ref>

===Addiction===

It is not clear whether using e-cigarettes will decrease or increase overall nicotine addiction.<ref name=Palazzolo/> The [[National Institute on Drug Abuse]] stated that there is a possibility that they could promote continuation of addiction to nicotine in those who are attempting to quit.<ref name=DrugFacts2014/> A number of organizations have concerns that e-cigarettes might increase addiction to and use of nicotine and tobacco products in the young.<ref name=MMWR2013>{{cite journal|last=Centers for Disease Control and Prevention|first=(CDC)|title=Notes from the field: electronic cigarette use among middle and high school students – United States, 2011–2012|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm |journal=MMWR. Morbidity and mortality weekly report|date=6 September 2013|volume=62|issue=35|pages=729–30|pmid=24005229}}</ref><ref name=DrugFacts2014>{{cite web|title=DrugFacts: Electronic Cigarettes (e-Cigarettes)|url=http://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes|work=National Institute on Drug Abuse|accessdate=15 October 2014|date=September 2014|quote=There is also the possibility that they could perpetuate the nicotine addiction and thus interfere with quitting.}}</ref><ref>{{cite web|title=Citing Health Concerns the American Cancer Society Calls for Action|url=http://www.cancer.org/myacs/eastern/areahighlights/cancernynj-news-ny-ecig-health-vote|work=American Cancer Society|accessdate=12 November 2013|quote=Government agencies and medical organizations, such as the FDA, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics have also expressed concern that electronic cigarettes could increase nicotine addiction and tobacco use in young people.}}</ref> This including: the Centers for Disease Control and Prevention, the [[International Union Against Tuberculosis and Lung Disease]], the [[American Academy of Pediatrics]] and the Food and Drug Administration.<ref name=CDCQ&A/><ref name=IUATLD/><ref>{{cite web|last=Korioth|first=Trisha|title=E-cigarettes easy to buy, can hook kids on nicotine|url=http://aapnews.aappublications.org/content/early/2013/10/04/aapnews.20131004-4|work=The American Academy of Pediatrics|accessdate=17 November 2013}}</ref><ref name=FDAConsumer2009>{{cite web|title=FDA Warns of Health Risks Posed by E-Cigarettes|url=http://www.fda.gov/forconsumers/consumerupdates/ucm173401.htm|work=FDA|accessdate=17 November 2013|date=23 July 2009|postscript=—Reviewed 17 September 2013}}</ref> The World Health Organization raised concern of addiction for nonsmokers from their use in July 2013.<ref name=WHOJuly2013/> A 2014 systematic review found these concerns that e-cigarettes could cause non-smokers to begin smoking are unsubstantiated.<ref name=FarsalinosPolosa2014/> A 2014 review found no evidence that they are used regularly by those who have never smoked,<ref name=Haj2014>{{cite journal|last1=Hajek|first1=P|last2=Etter|first2=JF|last3=Benowitz|first3=N|last4=Eissenberg|first4=T|last5=McRobbie|first5=H|title=Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit.|journal=Addiction (Abingdon, England)|date=31 July 2014|pmid=25078252}}</ref> while a 2014 review has found that in some populations nearly up to a third of youth who have ever used electronic cigarettes have never smoked traditional cigarettes.<ref name=Grana2014/> No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco dependence.<ref name=Drummond2014/> The degree to which teens are using e-cigarettes in ways it is not intended to be used, such as increasing the nicotine delivery, is unknown.<ref name=Durmowicz2014/> The extent to which e-cigarette use will lead to abuse in youth is unknown.<ref name=Durmowicz2014/> E-cigarette use on children in respect to nicotine dependence is unknown.<ref name=Durmowicz2014>{{cite journal|last1=Durmowicz|first1=E. L.|title=The impact of electronic cigarettes on the paediatric population|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii41–ii46|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051468|pmid=24732163}}</ref>

=== Construction ===

[[File:Components of a MiniCiggy e-cigarette.jpg|thumb|Disassembled cigarette-styled electronic cigarette.<br />A. [[Light-emitting diode|LED]] light cover<br />B. [[battery (electricity)|battery]] (also houses circuitry)<br />C. atomizer (heating element)<br />D. cartridge (mouthpiece)]]