Electronic Cigarette

Aka: Electronic Cigarette, E-Cigarette, E-Cig, E-Pipe, E-Cigar, Vaping, Juul

1. See Also
   1. Vaping-Associated Lung Disease
   2. Nicotine Replacement
   3. Tobacco Abuse
   4. E-Cigarette Cessation
2. Epidemiology
   1. Relative Risk of Tobacco Abuse among teens using e-cigs: 4 fold increase
   2. Of teens, 80% have the misconception that Vaping is harmless
   3. Prevalence (U.S.)
      1. High School: 1 in 9 (increased to 1 in 4 as of 2019)
      2. Middle School: 1 in 30
      3. Adults: 5%
3. Background
   1. In U.S., FDA will regulate e-cigs as Tobacco products as of August 2016
4. Mechanism
   1. Battery powered electronic device vaporizes a concentrated nicotine liquid in a replaceable cartridge
   2. User inhales nicotine vapor (or in some cases Marijuana or other substances)
   3. Various nicotine preparations are sold and not regulated
   4. Some nicotine solutions are flavored or colored (attracting young children)
   5. Nicotine concentrations vary by device
      1. Juul 5% (high concentration)
         1. Contains 40 mg nicotine per pod (equivalent to one pack of Cigarettes)
      2. Blu 1.2%
         1. Contains 18 mg nicotine per pod (slightly less than one half pack of Cigarettes)
      3. Labeling of nicotine concentration is highly inaccurate
         1. Raymond (2018) J Addict Med 12(2):127-31 +PMID:29280749 [PubMed]
   6. Pods (e.g. Juul) are alternative devices (appear similar to US drives)
      1. May be filled with high concentration nicotine or THC
5. Precautions
   1. Not recommended as Nicotine Replacement
      1. However in a COPD patient who refuses to quit nicotine, e-cigs appear to cause less harm than Tobacco
      2. Cibella (2016) Clin Sci 130(21): 1929-37 [PubMed]
      3. Polosa (2016) Respir Res 17(1): 166 [PubMed]
   2. NOT a Nicotine Replacement device (unlike Nicotine Patch, Nicotine Gum)
      1. E-Cigarette may replace Tobacco, but subsequently weaning from E-Cig often fails (in contrast to Nicotine Replacement)
      2. Hajek (2019) N Engl J Med 380(7):629-37 [PubMed]
   3. New, inventive way for companies (several that market Tobacco) to market an unregulated (in 2014), addictive nicotine product
   4. E-Cigarette has had a recent increase in use among U.S. high school students
   5. Nicotine solutions are not regulated and their labels may be inaccurate and their contents contaminated
      1. Inadequate safety data available for these devices and the inhaled vapor compared other Nicotine Replacement forms
6. Adverse Effects: Nicotine toxicity
   1. Nicotine solution is sold in large refillable 100 mg bottles
   2. Nicotine solutions are highly concentrated (up to 100 mg/ml)
   3. The solution is well absorbed by the gastrointestinal tract
   4. Toxicity risk is high when ingested by young children
      1. Toddlers experience symptoms with 1 mg ingestion
      2. Lethal dose at 6-13 mg/kg
   5. Nicotine has a Succinylcholine-like stimulatory effect on nicotinic receptors
      1. Results in Seizures followed by paralysis
   6. Nicotine affects teens differently than adults
      1. Teens are more likely to become addicted than adults
      2. Teens have a more significant adverse cognitive effect on memory and attention
      3. Teens are more likely to have respiratory adverse effects
   7. Longterm Vaping adverse cardiopulmonary effects are not yet clear
      1. May have carcinogenic effects
      2. Second hand exposure of potential toxins for friends and family
7. Adverse Effects: Miscellaneous
   1. See Vaping-Associated Lung Disease
   2. Heavy metal toxin contaminant exposure
      1. Lead
      2. Chromium
      3. Arsenic
      4. Propylene Glycol
      5. Formaldehyde
      6. Hydrogen cyanide has been isolated from black market cannibis Vaping solutions
   3. Nicotine is Teratogenic (effects fetal brain structure and function)
   4. E-Cigarette use increases increases risk of starting to use Cigarettes (Odds Ratio 3-6) and Marijuana
      1. Soneji (2017) JAMA Pediatr 171(8): 788-97 [PubMed]
      2. Dai (2018) Pediatrics 141(5): e20173787 [PubMed]
   5. E-Cigarette second-hand smoke exposure is common in middle and high school and triggers Asthma attacks
      1. Bayly (2019) Chest 155(1): 88-93 [PubMed]
8. Signs: Toxic Ingestion (children)
   1. Nausea
   2. Vomiting
   3. Seizures
      1. Onset within 2 hours of ingestion (and typically within 15-30 minutes)
   4. Paralysis
      1. Follows Seizures
9. Management: Toxic ingestion (children)
   1. Seizures
      1. Treat with Benzodiazepines
      2. See Status Epilepticus
   2. Paralysis or fasciculations
      1. Intubate under Rocuronium (avoid Succinylcholine)
      2. Post-intubation sedation with Benzodiazepines
10. Prevention
    1. See E-Cigarette Cessation (same as Tobacco Cessation)
    2. Try to prevent teens from using e-cigs before they start
11. Resources
    1. Electronic nicotine delivery systems: is there a need for regulation?
       1. http://www.talbotcentral.ucr.edu/AAA_04_publications/Electronic nicotine delivery systems is there a need for regulation.pdf
    2. Berkeley Wellness: Why Tobacco Companies Love E-Cigs
       1. http://www.berkeleywellness.com/self-care/over-counter-products/article/why-tobacco-companies-love-e-cigarettes
12. References
    1. (2018) Presc Lett 25(11): 64
    2. (2014) Presc Lett 21(6): 36
    3. Swadron and Nordt in Herbert (2014) EM:Rap 14(6): 14
    4. Klein (2019) Am Fam Physician 100(4): 227-35 [PubMed]
    5. Vardavas (2012) Chest 141(6):1400-6 [PubMed]
    6. Trtchounian (2011) Tob Control 20:47-52 [PubMed]