User:Jd4x4/Jd4x4/sandbox:ECigReorg

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Electronic Cigarette (Reorganisation proposal)

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An electronic cigarette, also known as e-cigarette among other names^{[notes 1]}, are noncombustible tobacco products.Cite error: A <ref> tag is missing the closing </ref> (see the help page). Using an e-cigarette is called "vaping" and the user is called a "vaper."^[2] Instead of cigarette smoke, the user inhales an aerosol, commonly called vapor.^[3] E-cigarettes typically have a heating element that atomizes a liquid solution called e-liquid.^[4] E-cigarettes are automatically activated by taking a puff;^[5] others turn on manually by pressing a button.^[2] Some e-cigarettes look like traditional cigarettes,^[6] but they come in many variations.^[2] Most versions are reusable.^[7] There are also pod mod devices that use nicotine in the form of a protonated nicotine, rather than free-base nicotine found in earlier generations.^[8] E-liquids usually contain propylene glycol, glycerin, nicotine, flavorings, additives, and differing amounts of contaminants.^[9]

E-cigarettes create vapor made of fine and ultrafine particles of particulate matter,^[10] which contain propylene glycol, glycerin, nicotine, flavors, small amounts of toxicants,^[10] carcinogens,^[11] heavy metals, metal nanoparticles, and other substances.^[10] Its exact composition varies, and depends on e-liquid contents, the device design, and user behavior, among other factors.^{[notes 2][3]} E-cigarette vapor contains fewer toxic chemicals, in lower concentrations, than cigarette smoke, but does potentially contain harmful chemicals not found in tobacco smoke.^{[10] [12] [13]} The vapor is probably much less harmful to users and bystanders than cigarette smoke,^[11] although concern exists that the exhaled vapor may be inhaled by non-users, particularly indoors.^[14]

Construction

As the e-cigarette industry continues to evolve, new products are quickly developed and brought to market.^[15] First-generation e-cigarettes tend to look like traditional cigarettes and so are called "cigalikes".^[16] Most cigalikes look like cigarettes but there is some variation in size.^[17] Second-generation devices are larger overall and look less like traditional cigarettes.^[18] There are first-generation,^[17] second-generation,^[18] third-generation,^[16] and fourth-generation devices.^[19] Third-generation devices include mechanical mods and variable voltage devices.^[16] The fourth-generation includes Sub ohm tanks (meaning that they have electrical resistance of less than 1 Ohm) and temperature control devices.^[19] The voltage for first-generation e-cigarettes is about 3.7^[20] and second-generation e-cigarettes can be adjusted from 3 V to 6 V,^[21] while more recent devices can go up to 8 V.^[20] The latest generation of e-cigarettes are pod mods,^[8] which provide higher levels of nicotine than regular e-cigarettes^[22] through the production of aerosolized protonated nicotine.^[23]

E-liquid is the mixture used in vapor products such as e-cigarettes^[24] and usually contain propylene glycol, glycerin, nicotine, flavorings, additives, and differing amounts of contaminants.^[9] E-liquid formulations greatly vary due to fast growth and changes in manufacturing designs of e-cigarettes.^[17] The composition of the e-liquid for additives such as nicotine and flavors vary across and within brands.^[25] The liquid typically consists of a combined total of 95% propylene glycol and glycerin, and the remaining 5% being flavorings, nicotine, and other additives.^[26] There are e-liquids sold without propylene glycol,^[27] nicotine,^[28] or flavors.^[29] The flavorings may be natural, artificial,^[25] or organic.^[30] Over 80 chemicals such as formaldehyde and metallic nanoparticles have been found in the e-liquid.^[31] There are many e-liquids manufacturers in the US and worldwide,^[32] and more than 15,500 flavors existed in 2018.^[33] Under the US Food and Drug Administration (US FDA) rules, e-liquid manufacturers are required to comply with a number of manufacturing standards.^[34] The revision to the EU Tobacco Products Directive has some standards for e-liquids.^[35] Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA).^[36]

Use

Popularity

Since the introduction of e-cigarettes into global markets, their usage has risen exponentially.^[14] In 2011 there were about 7 million adult e-cigarette users globally in 2011 rising to 41 million in 2018.^[37] Awareness and use of e-cigarettes greatly increased over the few years leading up to 2014, particularly among young people and women in some parts of the world.^[38] Since their introduction vaping has increased in the majority of high-income countries.^[39] E-cigarette use is highest in China, the US, and Europe,^[5] with China having the greatest number of e-cigarette users.^[40] Growth in the UK as of January 2018^[update] had reportedly slowed since 2013.^[41] The growing frequency of e-cigarette use may be due to heavy promotion in youth-driven media channels, their low cost, and the misbelief that e-cigarettes are safer than traditional cigarettes, according to a 2016 review.^[42]

The prevalence of vaping among adolescents is increasing worldwide.Schneider, Sven; Diehl, Katharina (2016). "Vaping as a Catalyst for Smoking? An Initial Model on the Initiation of Electronic Cigarette Use and the Transition to Tobacco Smoking Among Adolescents". Nicotine & Tobacco Research. 18 (5): 647–653.

There are varied reasons for e-cigarette use.[5] Most users' motivation is related to trying to quit smoking, but a large proportion of use is recreational.^[5] Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking cessation, as a safer alternative to traditional cigarettes, and as a way to conveniently get around smoke-free laws.^[51] Many users vape because they believe it is healthier than smoking for themselves or bystanders.^[6] Usually, only a small proportion of users are concerned about the potential adverse health effects.^[6] Seniors seem to vape to quit smoking or to get around smoke‐free policies.^[53] There appears to be a hereditary component to tobacco use, which probably plays a part in transitioning of e-cigarette use from experimentation to routine use.^[4] The introduction of e-cigarettes has given cannabis smokers a different way of inhaling cannabinoids.^[54] Recreational cannabis users can individually "vape" deodorized or flavored cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as "stealth vaping".^[54]

• Growth in the U.S.

In a 2014 survey, about 13% of American high school students reported using them at least once in the previous month,^[55] and in 2015 around 10% of American adults were users.^[56]

• Growth in the U.K.

In the UK, users have increased from 700,000 in 2012 to 2.6 million in 2015.^[57] About 60% of UK users are smokers and about 40% are ex-smokers, while use among never-smokers in the UK is negligible.^[57] Most still use traditional cigarettes, raising concern that dual use may "delay or deter quitting".^[10] Most peoples' reason for using e-cigarettes involve trying to quit smoking, though a large proportion use them recreationally.^[5] It is commonly stated that the modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, but tobacco companies had been developing nicotine aerosol generation devices since as early as 1963.^[58] As of 2018^[update], 95% of e-cigarettes were made in China.^[8]

Progression

Many users may begin by using a disposable e-cigarette.^[59] Users often start with e-cigarettes resembling traditional cigarettes, eventually moving to a later-generation device.^[60] Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit",^[60] and users may adjust their devices to provide more vapor for better "throat hits".^[61] A 2014 study reported that experienced users preferred rechargeable e-cigarettes over disposable ones.^[52] The most commonly used e-cigarettes in the UK are devices with refillable tanks.^[62] Most users used either closed systems or open systems, and rarely used both.^[52] Women were found to prefer disposable e-cigarettes, and young adults were found to pay more attention to modifiability.^[52] Modifiability also was found to increase the probability of initiating e-cigarettes among adolescents.^[52]

A 2013 study found that about three-fourths of smokers used a tank system, which allows users to choose flavors and strength to mix their own liquid.^[52] Experienced e-cigarette users even ranked the ability to customize as the most important characteristic.^[52] Users ranked nicotine strength as an important factor for choosing among various e-cigarettes, though such preference could vary by smoking status, e-cigarette use history, and gender.^[52] Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes.^[52] There is an abundance of colors, designs, carrying cases, and accessories to accommodate the diversity in personal preferences.^[59]

Youth

The prevalence of vaping among adolescents is increasing worldwide.^[64] There is substantial variability in vaping in youth worldwide across countries.^[43] Over the years leading up to 2017 vaping among adolescents has grown every year since these devices were first introduced to the market.^[44] There appears to be an increase of one-time e-cigarette use among young people worldwide.^[45] The frequency of vaping in youth is low.^[59] The result of youth e-cigarette use leading to smoking is unclear.^[46] Most e-cigarette users among youth have never smoked.^[46] Many youth who use e-cigarettes also smoke traditional cigarettes.^[10] Some youths who have tried an e-cigarette have never used a traditional cigarette; indicating e-cigarettes may be a starting point for nicotine use.^[10] Adolescents who would have not been using nicotine products to begin with are vaping.^[65] Twice as many youth vaped in 2014 than also used traditional cigarettes.^[66] Vaping seems to be a gateway to using traditional cigarettes in adolescents.^[47] Youth who use e-cigarettes are more likely to go on to use traditional cigarettes.^[48][49] The evidence suggests that young people who vape are also at greater risk for subsequent long-term tobacco use.^[50] E-cigarettes are expanding the nicotine market by attracting low-risk youth who would be unlikely to initiate nicotine use with traditional cigarettes.^[51] Data from a longitudinal cohort study of children with alcoholic parents found that adolescents (both middle and late adolescence) who used cigarettes, marijuana, or alcohol were significantly more likely to have ever used e-cigarettes.^[67] Adolescents were more likely to initiate vaping through flavored e-cigarettes.^[52] Among youth who have ever tried an e-cigarette, a majority used a flavored product the first time they tried an e-cigarette.^[67] There is a greater likelihood of past or present and later cannabis use among youth and young adults who have vaped.^[68]

Most youth are not vaping to help them quit tobacco.^[70] Adolescent vaping is unlikely to be associated with trying to reduce or quit tobacco.^[71] Adolescents who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.^[46] Vaping is correlated with a higher occurrence of cigarette smoking among adolescents, even in those who otherwise may not have been interested in smoking.^[72] Adolescence experimenting with e-cigarettes appears to encourage continued use of traditional cigarettes.^[73] A 2015 study found minors had little resistance to buying e-cigarettes online.^[12] Teenagers may not admit using e-cigarettes, but use, for instance, a hookah pen.^[74] As a result, self-reporting may be lower in surveys.^[74] Experts suggest that candy-like flavors could lead youths to experiment with vaping.^[75] E-cigarette advertisements seen by youth could increase the likelihood among youths to experiment with vaping.^[76] A 2016 review found "The reasons for the increasing use of e-cigarettes by minors (persons between 12 and 17 years of age) may include robust marketing and advertising campaigns that showcase celebrities, popular activities, evocative images, and appealing flavors, such as cotton candy."^[77] A 2014 survey stated that vapers may have less social and behavioral stigma than cigarette smokers, causing concern that vaping products are enticing youth who may not under other circumstances have used these products.^[78] The frequency of vaping is higher in adolescent with asthma than in adolescent who do not have asthma.^[79]

Motivation

E-cigarettes can have a high-tech look.^[80]

E-liquid comes in candy, fruit and coffee flavors, etc.^[81]

There are varied reasons for e-cigarette use.^[5] Most users' motivation is related to trying to quit smoking, but a large proportion of use is recreational.^[5] Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking cessation, a belief that they are a safer alternative to traditional cigarettes, and as a way to conveniently get around smoke-free laws.^[51] Some users vape for the enjoyment of the activity.^[6] Many e-cigarette users use them because they believe they are safer than traditional cigarettes.^[82] People who think they pose less risk than cigarette smoking are more likely to vape.^[83] A 2017 report found that smokers who previously vaped and quit though continued smoking, 51.5% believed that vaping is less risky than smoking ^[84] In contrast, 90% of former-smokers who vape believed vaping as less risky than cigarettes.^[84] A 2017 report found that a minority of the respondents believed that replacing cigarettes with e-cigarettes would be helpful for their health.^[85] Many users vape because they believe it is healthier than smoking for themselves or bystanders.^[6] Usually, only a small proportion of users are concerned about the potential adverse health effects.^[6] Some people say they want to quit smoking by vaping, but others vape to circumvent smoke-free laws and policies, or to cut back on cigarette smoking.^[10] 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking.^[86] In the same survey, 26% of respondents would use them in areas where smoking was banned.^[86] Continuing dual use among smokers is correlated with trying to cut down on smoking and to get around smoking bans, increased desire to quit smoking, and a decreased smoking dependence.^[87] Seniors seem to vape to quit smoking or to get around smoke‐free policies.^[53] Concerns over avoiding stains on teeth or odor from smoke on clothes in some cases prompted interest in or use of e-cigarettes.^[6] Some e-cigarettes appeal considerably to people curious in technology who want to customize their devices.^[88] There appears to be a hereditary component to tobacco use, which probably plays a part in transitioning of e-cigarette use from experimentation to routine use.^[4]

It is conceivable that former smokers may be tempted to use nicotine again as a result of e-cigarettes, and possibly start smoking again.^[7] E-liquid flavors are enticing to a range of smokers and non-smokers.^[89] Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one.^[90] College students often vape for experimentation.^[2] Millions of dollars spent on marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use".^[91] Marketing messages echo well-established cigarette themes, including freedom, good taste, romance, sexuality, and sociability as well as messages stating that e-cigarettes are healthy, are useful for smoking cessation, and can be used in smoke free environments.^[51] These messages are mirrored in the reasons that adults and youth cite for using e-cigarettes.^[51] Exposure to e-cigarette advertising influences people to try them.^[74]

The belief that e-cigarettes are safer than traditional cigarettes could widen their use among pregnant women.^[71] If tobacco businesses persuade women that e-cigarettes are a small risk, non-smoking women of reproductive age might start using them and women smoking during pregnancy might switch to their use or use these devices to reduce smoking, instead of quitting smoking altogether.^[9] Traditional cigarette users who have not used e-cigarettes had mixed ideas about their possible satisfaction and around a third thought that e-cigarettes might taste bad.^[6] Among current e-cigarette users, e-liquid flavor availability is very appealing.^[93] They feel or taste similar to traditional cigarettes, and vapers disagree about whether this is a benefit or a drawback.^[6] Some users like that e-cigarettes resembled traditional cigarettes, but others did not.^[6] E-cigarettes users' views about saving money from using e-cigarettes compared to traditional cigarettes are inconsistent.^[6] The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.^[6]

Some users stopped vaping due to issues with the devices.^[6] Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use.^[94] Commonly reported issues with using e-cigarettes were that the devices were hard to refill, the cartridges might leak and that altering the dose was hard.^[95] Smokers mainly quit vaping because it did not feel similar to traditional cigarettes, did not aid with cravings, and because they wanted to use them only to know what they were like.^[87]

Gateway theory

In the context of drugs, the

The "catalyst model" suggests that vaping may proliferate smoking in minors by sensitizing minors to nicotine with the use of a type of nicotine that is more pleasing and without the negative attributes of regular cigarettes.[108] A 2016 review, based on the catalyst model, "indicate that the perceived health risks, specific product characteristics (such as taste, price and inconspicuous use), and higher levels of acceptance among peers and others potentially make e-cigarettes initially more attractive to adolescents than tobacco cigarettes. Later, increasing familiarity with nicotine could lead to the reevaluation of both electronic and tobacco cigarettes and subsequently to a potential transition to tobacco smoking."^[64]

Health effects

The benefits and the

E-cigarette use was also rising among women, including women of childbearing age as of 2014[update],^[125] but the rate of use during pregnancy is unknown.^[9] Many woman still vape during pregnancy because of their perceived safety in comparison with tobacco.^[53] In one of the few studies identified, a 2015 survey of 316 pregnant women in a Maryland clinic found that the majority had heard of e-cigarettes, 13% had ever used them, and 0.6% were current daily users.^[67] These findings are of concern because the dose of nicotine delivered by e-cigarettes can be as high or higher than that delivered by traditional cigarettes.^[67] The rate of e-cigarette use among pregnant adolescents is unknown.^[67]

As of 2018, the health effects of Electronic Cigarette Use in Pregnancy for mother or fetus remain unknown. In it's summary review ^[126] the U.S. National Institute of medicine concluded that "Although the extensive research on tobacco and limited evidence on nicotine in isolation gives some focus to the questions regarding the potential effects of e-cigarettes, the need for direct evaluation is clear.", (Conclusion 13-1) "There is no available evidence whether or not e-cigarettes affect pregnancy outcomes.", and (Conclusion 13-2) "There is insufficient evidence whether or not maternal e-cigarette use affects fetal development."^[127]

Smoking cessation

The available research on the safety and efficacy of e-cigarette use for

Studies pertaining to their potential impact on smoking reduction are very limited.[138] E-cigarette use may decrease the number of cigarettes smoked,^[139] but smoking just one to four cigarettes daily greatly increases the risk of cardiovascular disease compared to not smoking.^[10] The extent to which decreasing cigarette smoking with vaping leads to quitting is unknown.^[140] Randomized controlled trials have not shown that vaping is effective for quitting smoking.^[129] A 2016 meta-analysis based on 20 different studies found that smokers who used e-cigarettes were 28% less likely to quit than those who had not tried e-cigarettes.^[141] This finding persisted whether the smokers were initially interested in quitting or not.^[141] Tentative evidence indicates that health warnings on vaping products may influence users to give up vaping.^[142]

It is unclear whether e-cigarettes are only helpful for particular types of smokers.^[143] Vaping with nicotine may reduce tobacco use among daily smokers.^[144] Whether or not vaping is potentially effective for quitting smoking may rely upon whether it was used as part of making an effort to quit or not.^[138]

Vaping is not clearly more or less effective than regulated nicotine replacement products or 'usual care' for quitting smoking.

It is difficult to reach a general conclusion from e-cigarette use for smoking cessation because there are hundreds of brands and models of e-cigarettes sold that vary in the composition of the liquid.[113] E-cigarettes have not been subjected to the same type of efficacy testing as nicotine replacement products.^[150] The similarity of e-cigarettes' vapor, looking like cigarette smoke, may prolong traditional cigarette use for people who could have quit instead, but the growing support of e-cigarettes could put extra pressure on smokers to stop cigarette smoking because smoking may be seen as socially unacceptable compared to a smokeless e-cigarette.^[151] The evidence indicates smokers are more frequently able to completely quit smoking using tank devices compared to cigalikes, which may be due to their more efficient nicotine delivery.^[110] There is low quality evidence that vaping assists smokers to quit smoking in the long-term compared with nicotine-free vaping.^[110] Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine.^[152] A 2013 study in smokers who were not trying to quit, found that vaping, with or without nicotine decreased the number of cigarettes consumed.^[153] E-cigarettes without nicotine may reduce tobacco cravings because of the smoking-related physical stimuli.^[116] A 2015 meta-analysis on clinical trials found that e-cigarettes containing nicotine are more effective than nicotine-free ones for quitting smoking.^[152] They compared their finding that nicotine-containing e-cigarettes helped 20% of people quit with the results from other studies that found nicotine replacement products helps 10% of people quit.^[152] A 2016 review found low quality evidence of a trend towards benefit of e-cigarettes with nicotine for smoking cessation.^[133] In terms of whether flavored e-cigarettes assisted quitting smoking, the evidence is inconclusive.^[52]

The efficacy and safety of vaping for quitting smoking during pregnancy is unknown.^[154] No research is available to provide details on the efficacy of vaping for quitting smoking during pregnancy.^[155] There is robust evidence that vaping is not effective for quitting smoking among adolescents.^[72] In view of the shortage of evidence, vaping is not recommend for cancer patients.^[156] The effectiveness of vaping for quitting smoking among vulnerable groups is uncertain.^[157]

Harm reduction

The term

Tobacco smoke contains 100 known carcinogens, and 900 potentially cancer causing chemicals, but e-cigarette vapor contains less of the potential carcinogens than found in tobacco smoke.[27] A study in 2015 using a third-generation device found levels of formaldehyde were greater than with cigarette smoke when adjusted to a maximum power setting.^[29] E-cigarettes cannot be considered safe because there is no safe level for carcinogens.^[116] Due to their similarity to traditional cigarettes, e-cigarettes could play a valuable role in tobacco harm reduction.^[151] However, the public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear.^[151] Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.^[151]

The core concern is that smokers who could have quit entirely will develop an alternative nicotine addiction.^[116] Dual use may be an increased risk to a smoker who continues to use even a minimal amount of traditional cigarettes, rather than quitting.^[10] The promotion of vaping as a harm reduction aid is premature,^[115] while a 2011 review found they appear to have the potential to lower tobacco-related death and disease.^[116] Evidence to substantiate the potential of vaping to lower tobacco-related death and disease is unknown.^[155] The health benefits of reducing cigarette use while vaping is unclear.^[164] E-cigarettes could have an influential role in tobacco harm reduction.^[151] The authors warned against the potential harm of excessive regulation and advised health professionals to consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking.^[11] A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction.^[160] A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions.^[165] There is no research available on vaping for reducing harm in high-risk groups such as people with mental disorders.^[166]

A 2014 PHE report concluded that hazards associated with products currently on the market are probably low, and apparently much lower than smoking.^[161] However, harms could be reduced further through reasonable product standards.^[161] 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.^[167] 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 e-cigarettes and smokeless tobacco for long-term use instead of smoking.^[168] A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both.^[75] 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."^[75]

Safety

The risks of e-cigarette use are uncertain.

The

E-cigarettes create vapor that consists of fine and

Nicotine, a key ingredient

Nicotine is a

A 2015 American Academy of Pediatrics (AAP) policy statement stressed "the potential for these products to addict a new generation of youth to nicotine and reverse more than 50 years of public health gains in tobacco control."[78] The World Health Organization (WHO) is concerned about starting nicotine use among non-smokers,^[75] and the National Institute on Drug Abuse said e-cigarettes could maintain nicotine addiction in those who are attempting to quit.^[216] The limited available data suggests that the likelihood of abuse from e-cigarettes is smaller than traditional cigarettes.^[217] No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction,^[115] but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.^[2]

Following the possibility of nicotine addiction via e-cigarettes, there is concern that children may start smoking cigarettes.^[75] Adolescents are likely to underestimate nicotine's addictiveness.^[218] Vulnerability to the brain-modifying effects of nicotine, along with youthful experimentation with e-cigarettes, could lead to a lifelong addiction.^[74] A long-term nicotine addiction from using a vape may result in using other tobacco products.^[219] The majority of addiction to nicotine starts during youth and young adulthood.^[220] Adolescents are more likely to become nicotine dependent than adults.^[72] The adolescent brain seems to be particularly sensitive to neuroplasticity as a result of nicotine.^[199] Minimal exposure could be enough to produce neuroplastic alterations in the very sensitive adolescent brain.^[199] A 2014 review found that in studies up to a third of youth who have not tried a traditional cigarette have used e-cigarettes.^[10] The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown,^[177] as is the extent to which e-cigarette use may lead to addiction or substance dependence in youth.^[177]

Legislative, Scientific, and Medical Positions

Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries.^[185] The revised EU Tobacco Products Directive came into effect in May 2016, providing stricter regulations for e-cigarettes.^[221] As of August 2016, the US FDA extended its regulatory power to include e-cigarettes.^[222] Large tobacco companies have greatly increased their marketing efforts.^[115] As of 2014^[update], there were 466 brands of e-cigarettes.^[223] Global sales were around $19.3 billion in 2019.^[37]

The scientific community in US and Europe are primarily concerned with their possible effect on public health.^[224] There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to control tobacco,^[225] and serve as a gateway for smoking among youth.^[226] The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for quitting smoking is unclear.^[151] Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco.^[226] There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things.^[130]

Medical organizations differ in their views about the health implications of vaping.

In 1927, Joseph Robinson applied for a patent for an electronic vaporizer.[231] Its purpose was to be used with medicinal compounds.^[231] The patent was approved in 1930.^[232] The device was never made available for sale.^[232] In 1930, the United States Patent and Trademark Office reported a patent stating, "for holding medicinal compounds which are electrically or otherwise heated to produce vapors for inhalation."^[233] In 1934, a patent stated that a product was "adapted for transforming volatile liquid medicaments into vapors or into mists of exceedingly fine particles."^[233] In 1936, a comparable patent was reported.^[233] These instances are in regard to vaporization for medicinal use.^[233] The earliest e-cigarette can be traced to American Herbert A. Gilbert,^[234] who in 1963 patented "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air".^[235][236] This device produced flavored steam without nicotine.^[236] The patent was granted in 1965.^[237] Gilbert's invention was ahead of its time.^[238] There were prototypes, but it received little attention^[239] and was never commercialized^[236] because smoking was still fashionable at that time.^[240] Gilbert said in 2013 that today's electric cigarettes follow the basic design set forth in his original patent.^[237] The Favor cigarette, introduced in 1986, was another early noncombustible product promoted as an alternative nicotine-containing tobacco product.^[67]

Initially, their performance did not meet the expectations of users.[248] The e-cigarette continued to evolve from the first-generation three-part device.^[17] In 2007 British entrepreneurs Umer and Tariq Sheikh invented the cartomizer.^[249] This is a mechanism that integrates the heating coil into the liquid chamber.^[249] They launched this new device in the UK in 2008 under their Gamucci brand^[250] and the design is now widely adopted by most "cigalike" brands.^[17] Other users tinkered with various parts to produce more satisfactory homemade devices, and the hobby of "modding" was born.^[251] The first mod to replace the e-cigarette's case to accommodate a longer-lasting battery, dubbed the "screwdriver", was developed by Ted and Matt Rogers^[251] in 2008.^[248] Other enthusiasts built their own mods to improve functionality or aesthetics.^[251] When pictures of mods appeared at online vaping forums many people wanted them, so some mod makers produced more for sale.^[251]

In 2008, a consumer created an e-cigarette called the screwdriver.^[248] The device generated a lot of interest back then, as it let the user to vape for hours at one time.^[251] The invention led to demand for customizable e-cigarettes, prompting manufacturers to produce devices with interchangeable components that could be selected by the user.^[248] In 2009, Joyetech developed the eGo series^[249] which offered the power of the screwdriver model and a user-activated switch to a wide market.^[248] The clearomizer was invented in 2009.^[249] Originating from the cartomizer design, it contained the wicking material, an e-liquid chamber, and an atomizer coil within a single clear component.^[249] The clearomizer allows the user to monitor the liquid level in the device.^[249] Soon after the clearomizer reached the market, replaceable atomizer coils and variable voltage batteries were introduced.^[249] Clearomizers and eGo batteries became the best-selling customizable e-cigarette components in early 2012.^[248]

International tobacco companies dismissed e-cigarettes as a fad at first.

Consumers of e-cigarettes have shown passionate support for e-cigarettes that other nicotine replacement products did not receive.[161] They have the potential mass appeal that could challenge combustible tobacco's market position.^[161]

A subculture has emerged which calls itself "the vaping community".^[267][268] Members of this emerging subculture often see e-cigarettes as a safer alternative to smoking,^[11] and some view it as a hobby.^[269] The online forum E-Cig-Reviews.com was one of the first major communities.^[251] It and other online forums, such as UKVaper.org, were the origins of the hobby of modding.^[251] There are also groups on Facebook and Reddit.^[270] Online forums based around modding have grown in the vaping community.^[271] Vapers energetically embrace activities associated with e-cigarettes and in some circumstances act as unpaid evangelicals, according to a 2011 study.^[61] E-cigarette companies have a substantial online presence, as well as many individual vapers who blog and tweet about e-cigarette related products.^[272] A 2014 Postgraduate Medical Journal editorial stated that vapers "also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks".^[272] Contempt for Big Tobacco is part of vaping culture.^[273][274] A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda.^[10] The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws.^[10] This is similar to tobacco industry activity going back to the 1980s.^[10] These approaches were used in Europe to minimize the EU Tobacco Products Directive in October 2013.^[10] Grassroots lobbying also influenced the Tobacco Products Directive decision.^[275] Tobacco companies have worked with organizations conceived to promote e-cigarette use, and these organizations have worked to hamper legislation intended at restricting e-cigarette use.^[115]

A popular vaporizer used by American youth is the Juul.^[276] Close to 80% of respondents in a 2017 Truth Initiative study aged 15–24 reported using Juul also used the device in the last 30 days.^[277] Teenagers use the verb "Juuling" to describe their use of Juul,^[278] and Juuling is the subject of many memes on social media.^[279] Students commented on Twitter about using the Juul device in class.^[280]

Regulation of e-cigarettes varies across countries and states, ranging from no regulation to

E-cigarettes containing nicotine have been listed as drug delivery devices in a number of countries, and the marketing of such products has been restricted or put on hold until safety and efficacy clinical trials are conclusive.[316] Since they do not contain tobacco, television advertising in the US is not restricted.^[317] Some countries have regulated e-cigarettes as a medical product even though they have not approved them as a smoking cessation aid.^[180] A 2014 review stated the emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public and recommended that e-cigarettes should be regulated to protect consumers.^[160] It added, "heavy regulation by restricting access to e-cigarettes would just encourage continuing use of much unhealthier tobacco smoking."^[160] A 2014 review said regulation of the e-cigarette should be considered on the basis of reported adverse health effects.^[180]

Marketing

They are marketed to men, women, and children as being safer than traditional cigarettes.^[319] They are also marketed to non-smokers.^[40] E-cigarette marketing is common.^[225] There are growing concerns that e-cigarette advertising campaigns unjustifiably focus on young adults, adolescents, and women.^[172] Large tobacco companies have greatly increased their marketing efforts.^[115] This marketing trend may expand the use of e-cigarettes and contribute to re-glamorizing smoking.^[320] Some companies may use e-cigarette advertising to advocate smoking, deliberately, or inadvertently, is an area of concern.^[145] A 2014 review said, "the e-cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to promote cigarettes in the 1950s and 1960s."^[10] E-cigarette companies are using methods that were once used by the tobacco industry to persuade young people to starting using cigarettes.^[321] E-cigarettes are promoted to a certain extent to forge a vaping culture that entices non-smokers.^[321] Themes in e-cigarette marketing, including sexual content and customer satisfaction, are parallel to themes and techniques that have been found to be appealing to youth and young adults in traditional cigarette advertising and promotion.^[67] A 2017 review found "The tobacco industry sees a future where ENDS accompany and perpetuate, rather than supplant, tobacco use, especially targeting the youth."^[145] E-cigarettes and nicotine are regularly promoted as safe and even healthy in the media and on brand websites, is an area of concern.^[9]

While

Celebrity endorsements are used to encourage e-cigarette use.^[325] A 2012 national US television advertising campaign for e-cigarettes starred Stephen Dorff exhaling a "thick flume" of what the advertisement describes as "vapor, not tobacco smoke", exhorting smokers with the message "We are all adults here, it's time to take our freedom back."^[260] Opponents of the tobacco industry state that the blu advertisement, in a context of longstanding prohibition of tobacco advertising on television, seems to have resorted to advertising tactics that got former generations of people in the US addicted to traditional cigarettes.^[260] Cynthia Hallett of Americans for Non-Smokers' Rights described the US advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable".^[260] University of Pennsylvania communications professor Joseph Cappella stated that the setting of the advertisement near an ocean was meant to suggest an association of clean air with the nicotine product.^[260] In 2012 and 2013, e-cigarette companies advertised to a large television audience in the US which included 24 million youth.^[326] The channels to which e-cigarette advertising reached the largest numbers of youth (ages 12–17) were AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.^[326]

E-cigarettes are heavily promoted across all media outlets.^[72] They are vigorously advertised, mostly through the Internet, as a safe substitute to traditional cigarettes, among other things.^[14] E-cigarette companies promote their e-cigarette products on Facebook, Instagram,^[322] YouTube, and Twitter.^[327] They are promoted on YouTube by movies with sexual material and music icons, who encourage minors to "take their freedom back."^[145] They have partenered with a number of sports and music icons to promote their products.^[328] Tobacco companies intensely market e-cigarettes to youth,^[329] with industry strategies including cartoon characters and candy flavors.^[330] Fruit flavored e-liquid is the most commonly marketed e-liquid flavor on social media.^[331] E-cigarette companies commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as researchers have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum.^[12] The widespread assertion that e-cigarettes emit "only water vapor" is not true because the evidence demonstrates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and volatile organic compounds, in addition to particulate matter.^[13] Massive advertising included the assertion that they would present little risk to non-users.^[332] Though, "disadvantages and side effects have been reported in many articles, and the unfavorable effects of its secondhand vapor have been demonstrated in many studies."^[332] Many e-cigarette companies market their products as a smoking cessation aid without evidence of effectiveness.^[333] E-cigarette marketing has been found to make unsubstantiated health statements (e.g., that they help one quit smoking) including statements about improving psychiatric symptoms, which may be particularly appealing to smokers with mental illness.^[93] E-cigarette marketing advocate weight control and emphasize use of nicotine with many flavors.^[334] These marketing angles could particularly entice overweight people, youth, and vulnerable groups.^[334] Some e-cigarette companies state that their products are green without supporting evidence which may be purely to increase their sales.^[185]

Economics

The number of e-cigarettes sold increased every year from 2003 to 2014.^[17] In 2015 a slowdown in the growth in usage occurred in the US.^[335] As of January 2018, the growth in usage in the UK has slowed down since 2013.^[41] As of 2014^[update] there were at least 466 e-cigarette brands.^[336] Worldwide e-cigarette sales in 2014 were around US$7 billion.^[337] Worldwide e-cigarette sales in 2019 were about $19.3 billion.^[37] E-cigarette sales could exceed traditional cigarette sales by 2023.^[338] Approximately 30–50% of total e-cigarettes sales are handled on the internet.^[14] Established tobacco companies have a significant share of the e-cigarette market.^[74][339]

As of 2018^[update], 95% of e-cigarette devices were made in China,^[8] mainly in Shenzhen.^[340][341] Chinese companies' market share of e-liquid is low.^[342] In 2014, online and offline sales starting increases.^[343] Since combustible cigarettes are relatively inexpensive in China a lower price may not be large factor in marketing vaping products over there.^[343]

In 2015, 80% of all e-cigarette sales in convenience stores in the US were products made by tobacco companies.^[344] According to Nielsen Holdings, convenience store e-cigarette sales in the US went down for the first time during the four-week period ending on 10 May 2014.^[345] Wells Fargo analyst Bonnie Herzog attributes this decline to a shift in consumers' behavior, buying more specialized devices or what she calls "vapors-tanks-mods (VTMs)" that are not tracked by Nielsen.^[345] Wells Fargo estimated that VTMs accounted for 57% of the 3.5 billion dollar market in the US for vapor products in 2015.^[346] In 2014, dollar sales of customizable e-cigarettes and e-liquid surpassed sales of cigalikes in the US, even though, overall, customizables are a less expensive vaping option.^[347] In 2014, the Smoke-Free Alternatives Trade Association estimated that there were 35,000 vape shops in the US, more than triple the number a year earlier.^[348] However the 2015 slowdown in market growth affected VTMs as well.^[335] Large tobacco retailers are leading the cigalike market.^[349] "We saw the market's sudden recognition that the cigarette industry seems to be in serious trouble, disrupted by the rise of vaping," Mad Money's Jim Cramer stated April 2018.^[350] "Over the course of three short days, the tobacco stocks were bent, they were spindled and they were mutilated by the realization that electronic cigarettes have become a serious threat to the old-school cigarette makers," he added.^[350] In 2019, a vaping industry organization released a report stating that a possible US ban on e-cigarettes flavors can potentially effect greater than 150,000 jobs around the US.^[351]

The leading seller in the e-cigarette market in the US is the Juul e-cigarette,

In Canada, e-cigarettes had an estimated value of 140 million CAD in 2015.[356] There are numerous e-cigarette retail shops in Canada.^[357] A 2014 audit of retailers in four Canadian cities found that 94% of grocery stores, convenience stores, and tobacconist shops which sold e-cigarettes sold nicotine-free varieties only, while all vape shops stocked at least one nicotine-containing product.^[358]

By 2015 the e-cigarette market had only reached a twentieth of the size of the tobacco market in the UK.^[359] In the UK in 2015 the "most prominent brands of cigalikes" were owned by tobacco companies, however, with the exception of one model, all the tank types came from "non-tobacco industry companies".^[360] Yet some tobacco industry products, while using prefilled cartridges, resemble tank models.^[360]

France's e-cigarette market was estimated by Groupe Xerfi to be €130 million in 2015.^[361] Additionally, France's e-liquid market was estimated at €265 million.^[361] In December 2015, there were 2,400 vape shops in France, 400 fewer than in March of the same year.^[361] Industry organization Fivape said the reduction was due to consolidation, not to reduced demand.^[361]

Other names

Electronic cigarettes are variously known as e-cigarettes,^[10] e-Cigarettes,^[115] e-cigs,^[2] eCigs,^[362] E-Cigs,^[178] ECIGs,^[4] ECs,^[90] eCig vaping,^[363] electronic nicotine delivery devices (ENDD),^[364] electronic nicotine delivery systems (ENDS),^[228] electronic non-nicotine delivery systems (ENNDS),^[228] electrically heated cigarettes,^[365] non‐medicinal nicotine delivery systems (NMNDS),^[366] electrically heated smoking systems,^[365] electric cigarettes,^[237] electronic cigs,^[367] electronic smoking devices,^[368] electronic tobaccos,^[369] electronic vaping devices,^[370] electronic vaporizing devices,^[110] electronic vaporizers,^[371] electronic vaporisers,^[372] e-vaporizers,^[373] vaporizers,^[374] battery-powered devices,^[375] battery-powered vaporizers,^[376] personal battery powered vaporizers,^[377] personal vaporizers,^[378] personal vaporisers,^[379] (sp), PVs,^[371] vapourisers,^[380] advanced generation devices,^[60] advanced generation products,^[381] advanced refillable personal vaporizers^[230] advanced personal vaporizers,^[382] APVs,^[382] alternative nicotine delivery systems,^[159] ANDS,^[159] alternative nicotine products,^[383] vaporized nicotine products,^[384] VNPs,^[384] nicotine vaping products,^[385] NVPs^[385] disposable electronic cigarettes,^[386] disposable ECs,^[386] rechargeable e-cigarettes,^[387] digital cigarettes,^[388] digital vapor devices,^[389] e-vapor devices,^[390] vape devices,^[391] vaping devices,^[392] electronic vapor products,^[393] EVPs,^[393] e-vapor products,^[394] vapor products,^[383] vapor devices,^[395] vapour devices,^[392] vaporing devices,^[119] vaporizer pens,^[371] vapor pens,^[141] vape pens,^[374] vape pipes,^[12] vape sticks,^[42] vapes,^[396] cigalikes,^[71] cig-alikes,^[397] cig-a-likes,^[2] vapors-tanks-mods,^[345] VTMs,^[345] vape tanks,^[398] tanks,^[399] tank systems,^[392] eGo units,^[400] eGos,^[71] electronic cigarette mods^[401] electronic mods,^[402] e-cigarette mods,^[403] e-cig mods,^[403] mechanical e-cig mods,^[404] mechanical mods,^[402] mods,^[71] vape mods,^[405] pocket vapes,^[406] pod mods,^[22] pod vapes,^[406] pod systems,^[407] pod products,^[8] electronic cigars,^[408] e-cigars,^[409] electronic pipes,^[410] e-pipes,^[374] electronic hookahs,^[411] e-hookahs,^[412] hookah pens,^[412] hookah sticks,^[407] G-pens,^[371] electronic shishas,^[411] e-shishas,^[413] shisha pens,^[413] electronic smokes,^[414] e-smokes,^[415] electronic cigarillos,^[416] smokeless cigarillos,^[417] smokeless cigarettes,^[2] smokeless cigars,^[417] tobacco-free electronic cigarettes,^[408] tobacco-free cigarettes,^[156] vaporettes,^[2] technofoggers,^[2] or cloud-chasing vaporizers.^[44]

Related technologies

Other devices to deliver inhaled nicotine have been developed.^[54] They aim to mimic the ritual and behavioral aspects of traditional cigarettes.^[54]

British American Tobacco, through their subsidiary Nicoventures, licensed a nicotine delivery system based on existing asthma inhaler technology from UK-based healthcare company Kind Consumer.^[418] In September 2014 a product based on this named Voke obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.^[419]

In 2011 Philip Morris International bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University.^[420] The technology is based on the chemical reaction between pyruvic acid and nicotine, which produces an inhalable nicotine pyruvate vapor.^[421] Philip Morris Products S.A. created a different kind e-cigarette named P3L.^[422] The device is supplied with a cartridge that contains nicotine and lactic acid in different cavities.^[422] When turned on and heated, the nicotine salt called nicotine lactate forms an aerosol.^[422]

The

In December 2013 Japan Tobacco launched Ploom in Japan.^[433] In January 2016 they launched Ploom TECH^[434] that produces a vapor from a heated liquid that moves through a capsule of granulated tobacco leaves.^[435] In 2016 British American Tobacco (BAT) released its own version of the heat but not burn technology called glo in Japan^[436] and Switzerland.^[437] It uses tobacco sticks rather than nicotine liquid,^[438] and does not directly heat or burn tobacco.^[439] In 2015 the glo iFuse was released in Romania by BAT.^[440] It uses a coil to heat a liquid that produces a vapor that moves through mixed tobacco.^[441] Heat-not-burn tobacco products were first introduced in 1988, but were not a commercial success.^[442]

BLOW started selling e-hookahs, an electronic version of the

• E-cigarette related media
• Robbing the Future - Advertising Aimed at Children.
• California teens talk about their real experiences with vaping.
• 
  In 2019 and 2020, an

  outbreak of lung injury was linked to vaping.^[449]
• Tobacco Use By Youth Is Rising – February 2019 – Vital Signs.
• Julius Dein Performs A Magic Trick on a Vape.

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• "Electronic nicotine delivery systems" (PDF). World Health Organization. 21 July 2014. pp. 1–13.
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