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quitting-smoking-with-electronic-cigarettes
Last year, the e-cigarette startup Juul broke into people's sight as a dark horse, raising billions of dollars, with a valuation of up to 16 billion US dollars. Capital has always been in motion. It is estimated that by 2023, the scale of the e-cigarette market will reach US$44.610 billion. So, do you understand electronic cigarettes?

There are many names for e-cigarette nicotine delivery systems. The most common is "electronic cigarette", but other terms such as electronic cigarettes, electronic hookahs, pen-type electronic cigarettes, and box-type electronic cigarettes are also commonly used terms. Recently, new products such as JUUL have created brand-centric terms ("JUULing") for product use. For, the entire category will be called "e-cigarettes".


    What is an electronic cigarette?

    Electronic cigarettes are devices that generate inhalable aerosols by heating liquid solutions to a sufficiently high temperature.

    Solutions, sometimes called e-liquids, usually include nicotine, flavoring agents, and humectants, such as propylene glycol, to retain moisture and create aerosols when heated.

    Due to the lack of research on the safety of these compounds when inhaled, many flavors and moisturizers used in e-liquids have been approved by the Food and Drug Administration for oral use, but not for inhalation.

    Some new e-cigarettes on the market contain nicotine salt (nicotine salt) in the e-liquid, which raises questions about the use, purpose, and safety of this new type of nicotine. The manufacturer of JUUL claims that their nicotine salt formula increases the speed and amount of nicotine entering the bloodstream compared to other formulas.

    Although the use of e-cigarettes is often referred to as "atomization", these devices produce aerosols instead of vapors. Unlike steam, which is just a substance in the form of a gas, the aerosol of an e-cigarette can contain tiny chemical particles (such as metals in heating coils) from liquid solutions and devices.


    quitting-smoking-with-electronic-cigarettes


    What types of e-cigarettes are there?

    Some electronic cigarettes are similar in design to ordinary cigarettes, while others are more like cigars, pipes, pens, and even USB flash drives.

    To explain the diversity of product designs, some researchers classify e-cigarettes as first-generation, second-generation, or third-generation devices.

    The first-generation e-cigarette is an e-cigarette that is very similar to cigarettes and is disposable.

    The second-generation e-cigarette is a larger, usually pen-shaped device that can be charged.

    Third-generation e-cigarettes refer to the current generation of e-cigarette devices, which are not like combustible cigarettes and usually have very large and sometimes customizable batteries. Some parts may be replaceable, which is why they are sometimes referred to as "cigarettes". These devices are refillable.


    quitting-smoking-with-electronic-cigarettes
    The evolution of e-cigarettes




    quitting-smoking-with-electronic-cigarettes
    Current electronic cigarettes


    Recently, electronic cigarettes with stylish, high-tech designs and fast-charging batteries have entered the market. One of these devices was launched by JUUL in 2016 and quickly became the leading e-cigarette product in early 2018. In addition, imitation products such as Suorin Drop and myblu have appeared. These products follow JUUL's blueprint to achieve a high-tech appearance and high nicotine content through the use of nicotine salt e-liquid formulations.


    Heating non-combustion products

    In addition to e-cigarette products, tobacco companies have also introduced "heating non-combustion" tobacco products. These devices work by heating tobacco instead of burning it. Sometimes, the tobacco is treated with a humectant, such as propylene glycol, to produce an aerosol that is inhaled by the user. Manufacturers claim that this delivery method is far less harmful than traditional cigarettes, but there are currently little data on the health effects of these devices (and most of the published content is provided by tobacco industry scientists).

    Although these products have not yet been approved by the U.S. Food and Drug Administration for use in the United States, a non-combustible product from Philip Morris International is currently applying for new product applications for IQOS. According to foreign market data submitted by Philip Morris, so far, in addition to cigarettes, dual-use of heat-not-burn products is the most important mode of use, which raises substantive questions about the impact on overall public health.


    How much nicotine does e-cigarette contain?

    The content of nicotine in e-cigarettes varies greatly, some of which are close to combustible cigarettes.

    Labels are not always a reliable indicator of nicotine content, because studies have found that e-cigarette label errors are a common problem.

    The use or modification of electronic cigarettes will affect the delivery of nicotine to individual users.

    Some e-cigarette products provide nicotine almost as effectively as cigarettes. For example, the manufacturer of JUUL e-cigarette claims that the product has the same nicotine content as traditional cigarettes, and its nicotine release rate is 2.7 times that of other e-cigarettes. Although this may make them more attractive to smokers as alternatives to cigarettes, it increases the likelihood of addiction among young people. Therefore, it is recommended that these products should be strictly regulated to reduce their dissolution and use.

    A recently published Truth Initiative study found that among current JUUL users, only 37% of adolescents and young people know that the product always contains nicotine.


    Are e-cigarettes as harmful as cigarettes?

    The use of electronic cigarettes is far less harmful to personal health than inhaling the smoke of combustible tobacco such as cigarettes and cigars. However, even though e-cigarettes contain much fewer toxins than combustible cigarettes, they are not free of toxins and still release harmful chemicals.

    Although the basic technology behind e-cigarettes is the same, there are huge differences in product categories, and there is no typical e-cigarette. These products have different ingredients and different hardware and provide highly variable amounts of nicotine and potentially toxic chemicals. This change has made it difficult to make overall public health recommendations for e-cigarettes and has prompted the need for supervision. Consumers need to consistently understand the products they get, especially from a product that delivers chemicals through frequent inhalation.


    quitting-smoking-with-electronic-cigarettes
    2017 National Youth Smoking Survey


    There is a lot of confusion about the health effects of electronic cigarettes. A 2015 study found that among adult smokers, 30.8% believed that e-cigarettes were as harmful as cigarettes, 4.3% believed that e-cigarettes were more harmful, 28.9% did not know, and only 36% believed that e-cigarettes Smoke is less harmful. Changes in product characteristics and the current regulatory system-there are few obstacles in selling e-cigarettes as entertainment devices, but there are many obstacles in selling products that quit or completely quit smoking-may exacerbate this confusion. These misunderstandings indicate that there is an opportunity to educate smokers on this issue, especially when public health authorities are convinced that a particular product has been reviewed for issues such as toxicity, nicotine delivery efficiency, basic consumer safety, and youth attractiveness.


    Dual-use of tobacco products

    Among all age groups, e-cigarettes are most commonly used by those who also use other tobacco products, such as combustible cigarettes. This model is often referred to as "dual-use" or "multiple tobacco use".

    Among adults, dual-use is a disturbing pattern because it suggests that some e-cigarette use may be supplementary smoking rather than replacing it. Since there is no safe level of smoking, people worry that this behavior will inhibit efforts to quit smoking completely. People choose to "reduce" rather than quit smoking altogether). This problem is a bit complicated, because some people who use e-cigarettes to quit smoking may experience a period of dual-use when changing products.

    Among young people, data is more difficult to interpret. Dual-use may indicate that young people who use other nicotine products are also more likely to use e-cigarettes because of shared personality traits. The 2018 report concluded that “a large amount of evidence shows that the use of e-cigarettes increases the risk of adolescents and young people using combustible tobacco cigarettes”, which shows that e-cigarette use itself is a risk factor, not just a correlation with smoking.

    Among adults in 2015, 58.8% of e-cigarette users also smoked.

    Among young people in 2015, 40% of e-cigarette users also smoked.

    In 2013 and 2014, only 6.1% of young people and 1.6% of adults used e-cigarettes exclusively.

    In 2015, 65.2% of young people who used e-cigarettes in the past 30 days also reported using another tobacco product during the same time period.

    In 2015, 5.9% of high school students have dedicated e-cigarette users, and 25.3% currently use any tobacco products.


    Usage mode

    In recent years, the use of e-cigarettes has increased, especially among teenagers and young people, who use e-cigarettes more than any other age group. Electronic cigarettes are now the most commonly used tobacco product among young people.


    1. Youth

    Between 2011 and 2017, the number of high schools and middle school students using e-cigarettes increased significantly. The 2017 American Youth Tobacco Survey found that in the past 30 days, 11.7% of high school students and 3.3% of middle school students used e-cigarettes, while in 2011, this proportion was 1.5% and 0.6%, respectively.

    The use of e-cigarettes has been shown to increase the likelihood of young people smoking, which has raised concerns that e-cigarettes act as entry-level nicotine products and may lead to the use of more dangerous nicotine products. The 2018 NASEM report concluded: “There is a lot of evidence that e-cigarette use increases the risk of young people and young people using combustible tobacco cigarettes.”

    Many young e-cigarette users do not know what products they use. A recent study found that 98.7% of e-cigarette products sold in convenience stores, supermarkets, and similar stores contain nicotine. However, many young people are not aware that the products they use contain nicotine. In fact, 60% of young people mistakenly believe that e-cigarettes are mainly made up of condiments.

    Teenage e-cigarette users cited taste as the reason they started using e-cigarettes. A study involving middle school and high school students found that 43% of young people who had used e-cigarettes tried it because of the attractive taste.


    2. Young people

    As young people, young people between the ages of 18 and 24 are increasingly using e-cigarettes. The number of young people who use e-cigarettes every day or several days has increased from 2.4% in 2012 and 2013 to 5.2% in 2015. (As shown below)


    quitting-smoking-with-electronic-cigarettes


    A report from the 2015 American Health Interview Survey pointed out that 40% of young people who use e-cigarettes every day or several days have never smoked before trying e-cigarettes.

    Compared with adults 25 years and older, young people are more likely to try e-cigarettes and report using e-cigarettes in the past 30 days.

    With the popularity of e-cigarettes among young people, people are beginning to worry that the use of e-cigarettes will lead to the use of cigarettes and other tobacco products.


    3. Adults

    In recent years, the use of e-cigarettes has also increased among adults, although much less than that of young people. Between 2012 and 2013, 2.4% of adults aged 25 to 44 used e-cigarettes, and among adults aged 45 to 64, the proportion was 2%. By 2016, this proportion had risen to 4.2% and 2.8%, respectively. (As shown below)


    quitting-smoking-with-electronic-cigarettes


    Compared with young people, adults aged 45 and above are significantly less likely to try e-cigarettes.

    In 2015, among adult e-cigarette users, 29.8% were former smokers, 58.8% were current smokers, and 11.4% had never smoked.


    Smoking tool?

    There is a huge research gap in proving the effectiveness of electronic cigarettes as a smoking cessation aid. The 2018 NASEM report found that there is limited evidence on the effect of e-cigarettes in promoting smoking cessation. In addition, the US Preventive Service Task Force does not approve e-cigarettes as a smoking cessation aid.

    However, there is some evidence to support the use of e-cigarettes as smoking cessation devices.

    A research report published in 2016 stated that in two randomized controlled trials, e-cigarettes containing nicotine were more effective than e-cigarettes without nicotine to quit smoking.

    NASEM also reported that more frequent use of e-cigarettes may increase the likelihood of individuals quitting smoking.

    Although some e-cigarettes may be effective resources for smoking cessation, changes in product quality and lack of supervision make it difficult to determine the potential of any particular product as a smoking cessation aid.

    Although there is currently limited research supporting the use of e-cigarettes for smoking cessation, smokers who switch to e-cigarettes will greatly reduce exposure to toxic chemicals and health risks. Some smokers have switched to e-cigarettes or quit smoking altogether. The Truth Initiative supports regulation and encourages the development of lower nicotine delivery alternatives to enable smokers to quit smoking completely or completely switch to less harmful products.

    The attractiveness of products, including flavors, may encourage smokers to try e-cigarettes to quit smoking. However, the taste is also attractive to young people, so manufacturers should be prohibited from selling flavored e-cigarettes unless they can prove that the product helps adults quit smoking and will not attract a large number of young people to accept it. The Truth Initiative supports strong regulations to keep all tobacco products, including e-cigarettes, away from young people.


    Health impact

    E-cigarettes are far less harmful than inhaling combustible tobacco smoke such as cigarettes and cigars. However, there are still many unknowns, and it is vital to continue to monitor the potential health effects, addiction, and toxicity of e-cigarettes.

    1. Addiction and brain development

    Nicotine is an addictive substance, but its degree of addiction will vary greatly depending on the way it is released. The nicotine produced by burning tobacco is the most addictive. E-cigarettes are becoming more and more popular, and people are beginning to worry about the potential risks of e-cigarette addiction. After all, the nicotine content of e-cigarettes is comparable to that of combustible cigarettes.

    Young people’s exposure to nicotine is particularly dangerous because it has been shown to have an effect on key brain receptors, making young people more susceptible to addiction.

    There is evidence that the effects of nicotine on brain development may lead to nicotine addiction and more easily addiction to other drugs.

    2.  Pregnancy

    Because many e-cigarettes contain nicotine, which can change the function of developing nerve cells, especially during fetal development, adolescents and pregnant women should not use e-cigarettes.
    Pregnant women who use nicotine are at higher risk of stillbirth and preterm birth

    3. Chemical substances

    Although e-cigarettes contain far fewer toxins than combustible cigarettes, they are not free of toxins and still release harmful chemicals.

    At least 60 compounds were found in the e-cigarette liquid of e-cigarettes, and more compounds were found in the aerosol produced by e-cigarettes.

    Researchers have identified several substances that are harmful or potentially harmful to e-cigarette users, including solvents and propylene glycol that can cause dry mouth and upper respiratory tract infections.

    The taste of e-cigarettes—even those approved for consumption—has not been studied for toxicity if inhaled for a long time. Many flavors of e-cigarettes contain chemicals that are known to irritate the respiratory tract. Studies have found that some flavors may be more toxic than others.

    For example, researchers found that increased exposure to cinnamon spice causes significant cell death compared to other flavors. In addition, mixing multiple flavors is more toxic to cells than just contacting one flavor at a time. The consequences of long-term exposure to chemicals found in e-cigarette liquids are not yet clear, because e-cigarette products have not been on the market long enough to conduct final research on their effects.

    4. Contact with e-liquid

    Accidental contact or ingestion of e-liquid can be very dangerous, and even fatal in the case of accidental swallowing or injection.

    5. Explosion

    Defective, inferior, and privately modified electronic cigarettes can explode and cause harm. The incidence of the explosion is unclear, but hospitals and burn centers have reported injuries caused by e-cigarettes.

    6. Exposure to second-hand aerosols

    E-cigarette aerosols may expose non-smokers to nicotine, but studies have shown that second-hand aerosols are much less toxic and carcinogenic than second-hand smoke. However, exposure to vulnerable groups including pregnant women and children is still at risk.


    The retail environment of e-cigarettes

    Electronic cigarettes are sold in traditional tobacco retail stores, such as convenience stores, gas stations, pharmacies, and tobacco stores. They are also sold in non-traditional stores, such as online retailers and e-cigarette stores.

    Due to the different ways of tracking e-cigarette sales, it is difficult to monitor and analyze the market. Common sales tracking and retail measurement companies, such as Nielsen, do not check e-cigarette store data, which is a large market share.

    Since non-traditional data sources are not tracked by scanner data or other tracking methods, it is difficult to know how much market share they represent. However, analysts also made some estimates. A paper pointed out that in 2014, traditional tobacco stores accounted for less than one-third of the US$2.5 billion e-cigarette market. According to a recent estimate, the retail channel breakdown of the e-cigarette market in 2018 is as follows:

    Electronic cigarette shops: 36.4%

    Convenience stores, food, medicine, and mass retail channels: 31.8%

    Online and other retail channels: 31.8%

    Recently, the US Food and Drug Administration condemned eBay for allowing JUUL and other tobacco products to enter the site, which is a clear violation of the company's policy. Therefore, eBay deleted the product listings and voluntarily took measures to prevent future sales. However, recent reviews on eBay found that JUUL’s equipment is still on sale and more personalized.




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