Understanding electronic nicotine delivery systems
Electronic Nicotine Delivery Systems (ENDS) are a product category that includes disposable cigarette-like e-cigarettes, e-hookah, vape pens, and refillable tank-like or personal vaporizers that do not look like cigarettes.
These devices heat a solution (usually propylene glycol or glycerin, with or without nicotine, often combined with additives and flavors) producing an aerosol mist that is inhaled without combustion. This inhalation is widely referred to as vaping.
The following questions and answers outline the Truth Initiative’s take on ENDS.
Is vaping safer than smoking?
Current evidence supports the conclusion that vaping poses significantly less risk of adverse health effects to an individual than smoking. Therefore, smokers who completely switch to ENDS as soon as possible are likely to experience a significant health benefit versus continued use of combustible tobacco products such as cigarettes, cigars, pipe, hookah and roll your own tobacco. Combustible tobacco is particularly hazardous because of the inhalation of smoke containing carbon monoxide, over 60 proven human cancer causing carcinogens and over 4,000 other chemicals (commonly called the tars). Because ENDS do not combust tobacco, they contain far fewer and lower concentrations of, toxicants than tobacco smoke and no carbon monoxide. But, they are not without risk. Because most ENDS contain nicotine, they should not be used by youth or those with conditions that contraindicate nicotine usage (such as pregnancy).
What are the health risks of ENDS and vaping?
Although vaping is substantially less harmful to an individual than smoking, it is not harmless. Indeed, because ENDS are a relatively new product, the health risks of ENDS are not fully known, particularly the long -term effects of inhaling nicotine, propylene glycol, flavors, or other ingredients in e-cigarette liquid. Moreover research shows that some ENDS products expose users to harmful constituents, including heavy metal particles, although at levels that are much lower than that of combustible cigarettes. Because ENDS are not regulated for quality or safety, the constituent profile can vary from product-to- product, and new product designs may present different individual health risks. Further, ENDS that do contain nicotine are harmful to certain populations (children, youth, pregnant women, those with heart disease and some other conditions). The likelihood of nicotine initiation through ENDS increasing the likelihood of other tobacco use (i.e. combustible tobacco forms) is not yet known. We do not yet know whether ENDS are an “on-ramp” to further tobacco use or a potential path away. More research is required to answer this question.
What is the quality of ENDS products?
There are many ENDS products and they are evolving rapidly. It is hard to keep pace with of all of them. ENDS vary in quality, constituents, safety, size, clarity of instructions and labeling and efficiency of nicotine delivery. No enforceable mechanisms currently exist to ensure good manufacturing and product standards, proper labeling and packaging, appropriate marketing and youth access restrictions. Product registration and regulation by the FDA is urgently needed to ensure all products (including future generations of ENDS) meet safety standards and sound, responsible marketing practices to protect consumers.
Do you have a position on ENDS?
We are dedicated to creating a generation for whom tobacco use is a thing of the past. Those who do not use tobacco, particularly young people, should never start using any tobacco or nicotine containing product, including ENDS. For tobacco users, we urge them to quit all tobacco use as soon as possible, and the earlier they stop the greater the health benefit. Therefore, our first recommendation is to use cessation treatments recommended by the USPHS Guidelines. However, we understand that some smokers may be unable or unwilling to quit smoking combustible cigarettes via these methods. In this case, ENDS could help smokers to reduce their harms by switching to exclusive use of ENDS or by using ENDS to quit use of all tobacco product s. That said, in order for ENDS to maximize the potential for positive public health effect, they must be prudently regulated by FDA. We believe that ENDS (and indeed all tobacco products) should be subject to youth access restrictions and marketing restrictions to prevent appeal and sales to youth. They must also have product standards to ensure they are as safe as possible and carry appropriate warnings and instructions for safe use and storage.
Do ENDS help people quit smoking cigarettes?
Our view of current evidence leads us to conclude that ENDS hold promise as a cessation tool. Indeed, accumulating evidence from recent studies suggests that ENDS, when used as a tool in a serious quit attempt, can be as effective as FDA-approved nicotine replacement therapies such as gums, patches and lozenges. That said, this evidence is preliminary. To determine just how effective ENDS are in helping people quit smoking cigarettes and how they might best be used as a tool for total cessation, we need more research, including randomized control trials. It is up to ENDS manufacturers to seek appropriate FDA approval to make cessation claims to consumers. To date they have not done so, and ENDS are not currently approved for smoking cessation by FDA.
Should young people use ENDS?
No. Young people should not use ENDS. Simply understood ENDS are drug delivery devices for nicotine, an addictive stimulant that can be harmful to youth and young adult brain development. ENDS clearly are not appropriate products for children and youth regardless of whether they lead to use of combustible tobacco or other risky behaviors. We are concerned with the recent large increases in last 30-day ENDS use among youth. We need to understand more about the patterns of use associated with those increases. We cannot yet conclude whether the increases are among youth who would otherwise have never used a nicotine product. Likewise we cannot yet answer whether youth are at risk for progression to chronic nicotine use, combustible tobacco use or use of other dangerous drugs.
How does ENDS use relate to other tobacco use? (Are they a gateway into or out of smoking?)
We simply do not know. Despite high rates of last 30-day use among youth, there is no current evidence that ENDS use has led to more youth nicotine use than otherwise would have been the case or that ENDS use is causing progression to combustible tobacco use that otherwise would not have occurred. While ENDS use has increased rapidly in recent years, during the same time period youth cigarette smoking has declined to record lows at faster than expected rates. However, at the same time, youth use of other combustible products such as little cigars and hookah has grown. In addition, we note the high rate of dual use of combustible tobacco products amongst youth reporting use of ENDS. We recognize that a certain amount of ENDS use is consistent with overall youth experimentation with other substances such as alcohol, marijuana and other tobacco products. We must continue to conduct research to determine the role ENDS use plays in the mix of other high-risk behaviors and progression to lifelong adverse consequences.
Can ENDS minimize harm?
While not as beneficial as complete cessation of all tobacco products, ENDS have potential to reduce health risks if used exclusively by a smoker who otherwise cannot or will not quit. We also believe ENDS have potential to reduce overall population harm resulting from combustible tobacco use, but only if they are prudently regulated, responsibly marketed to current adult smokers, and used to speed elimination of people inhaling the lethal, toxic smoke from combustible tobacco. If you are interested in reading more about harm minimization we have a more detailed statement on the issue you can read here.
What about youth smokers – should they switch to ENDS?
The best course of action for any youth smoker is to quit any and all forms of tobacco or nicotine use as early in life as possible. Currently, there are no USPHS-approved guidelines to help youth smokers quit. Barring such a guideline, in the case of an established youth smoker who is unable to quit via any other means despite best efforts, switching completely to ENDS will likely reduce their individual health risks, and might help them ultimately quit all tobacco use, including ENDS, which would be the preferred result.
Do you support flavors in ENDS?
We support a ban on flavors in all tobacco products. There is strong evidence showing that flavored tobacco products (e.g., menthol) are attractive to and used by a greater proportion of youth and young adults compared to adults. We have strongly supported a ban on menthol cigarettes and strongly support banning menthol and other flavors in other combustible products such as cigars and hookah. Likewise, flavors should be banned in ENDS, with the possible limited exception of a product whose manufacturer can demonstrate to FDA that the flavored ENDS product is not marketed to youth (i.e. is marketed solely to appeal to adult smokers) with careful post-market surveillance of actual usage patterns. There are, for example, nicotine replacement treatment options such as flavored gums that are not marketed to appeal to youth.
Should ENDS be included in smoke- or tobacco-free policies?
Yes. Clean air restrictions should be expanded to cover all tobacco products that produce smoke or aerosol. ENDS aerosol is an irritant, and contains nicotine, as well as other chemicals, to which certain groups (youth, pregnant women, those with heart disease, or with allergies to any of the chemicals, etc.) should not be exposed.
Should ENDS be taxed at all? If so, should they be taxed at the same rate as other tobacco products?
Research has shown that increasing the cost of tobacco use is one of the most powerful tools to reduce youth initiation of tobacco, and thus the death and disease burden from smoking. We believe that all tobacco products, including ENDS, should be taxed. However, we believe that ENDS should be taxed at a rate lower than combustible products so that smokers who will not or cannot quit will have an economic incentive to switch to ENDS. This should be accomplished by substantially increasing current taxes on combustibles and introducing proportionately lower tax rates on ENDS.