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EDITORIAL
Electronic cigarettes: ‘Vaping’ has unproven benefits and potential harm Key words: electronic cigarette, electronic nicotine delivery system, nicotine, smoking cessation, tobacco smoking. Abbreviations: APSR, Asian Pacific Society of Respirology; e-cigarette, electronic cigarette; ENDS, electronic nicotine delivery systems; FIRS, Forum of International Respiratory Societies.
The rapid increase in awareness and usage of electronic cigarettes (e-cigarettes) has prompted the Forum of International Respiratory Societies (FIRS) to recently publish a position statement that strongly opposes the unregulated production and use of e-cigarettes.1 The statement has been jointly endorsed by the American College of Chest Physicians, American Thoracic Society, Asociación Latinoamericana de Tórax, Asian Pacific Society of Respirology (APSR), European Respiratory Society, International Union Against Tuberculosis and Lung Disease (The Union) and Pan African Thoracic Society. ‘Electronic cigarettes’ or ‘electronic nicotine delivery systems’ (ENDS) are devices that deliver to the lung a vapourized liquid usually containing nicotine and other chemicals. The act of ‘vaping’ has been portrayed as a non-tobacco mimic that smokers can use to reduce the amount of cigarette consumption, almost like a smoking cessation tool. The appeal to users and primary concern for health advocates is the delivery of nicotine, a highly addictive substance.2 E-cigarettes have been claimed by some manufacturers to contain a lesser amount or even no nicotine, tar or carcinogens, than combustible cigarettes. However, in the current climate of inadequate or absent regulation, there exists insufficient information to objectively evaluate these claims. Manufacturers of e-cigarettes have reported that each replacement cartridge typically contains between 6 and 24 mg of nicotine, thereby mimicking the usual amount in nicotine gum or patch. However, external testing has shown the nicotine content of cartridges to be highly variable with some refill cartridges containing 100 mg of nicotine per millilitre.3 The role and safety of e-cigarettes and electronic nicotine delivery devices as nicotine replacement therapy remain unknown. This contrasts markedly with standard nicotine replacement therapy,4 which appear in the forms of gum, transdermal patch or lozenges. Such delivery systems were approved by regulatory agencies only after extensive study, have been shown to be safe and provide a well-defined amount of nicotine appropriate to aid smoking cessation.5 © 2014 Asian Pacific Society of Respirology
UNPROVEN BENEFIT OF BEING AN ALTERNATIVE TO CONVENTIONAL CIGARETTES While some studies have shown that individuals who do not intend to quit smoking can reduce their intake of combustible cigarettes with e-cigarettes,6,7 other studies have failed to show superiority of e-cigarettes over nicotine replacement medicine or placebo for individuals trying to quit smoking.8 The addictive power of nicotine and its untoward effects should not be underestimated.9 The potential benefits of electronic nicotine delivery devices, including harm reduction and as an aid to smoking cessation, have not been well studied.9,10
POTENTIAL HARMFUL EFFECTS SHOULD NOT BE OVERLOOKED Both combustible and e-cigarettes pose health risks to consumers. Awareness and use of e-cigarettes continue to spread rapidly and extensively.11,12 A particularly worrisome phenomenon is the common use of e-cigarettes among women, those who are less educated and adolescents.13–15 It is possible, therefore, that the use of e-cigarettes in these groups may actually encourage, rather than discourage, tobacco smoking in adolescents.14,15 Any harm reduction of nicotine is likely outweighed by its harmful effects on cardiac, respiratory, metabolic and neurological functions.16–18 Further, nicotine is potentially carcinogenic,19 regardless of whether directly ingested or absorbed through inhalation or via the skin surface.20 Inhalation of vapour from e-cigarette cartridges has been shown to augment inflammatory changes in mouse airway21 and shortterm usage of e-cigarettes has been shown to adversely affect lung function.22 Case reports have documented the development of lipoid pneumonitis23 and eosinophilic pneumonitis24 after the use of e-cigarettes in previously healthy individuals.
PUBLIC HEALTH CONCERN A public health concern is that the use of these products may increase the risk of non-smokers developing nicotine dependence and current smokers maintaining their dependence.25 Increased use, especially Respirology (2014) 19, 945–947 doi: 10.1111/resp.12374
946 among youth, has raised serious concerns about the overall impact of e-cigarettes on public health.12 At the population level, it is possible that the availability of e-cigarettes may have an overall adverse impact by increasing initiation and reducing cessation of smoking.1,26 Results are conflicting with one study showing e-cigarette use to be associated with a greater reduction in cigarettes per day over time, compared with individuals who did not use them.10 However, another study showed that e-cigarette users were not more likely to quit smoking than those who did not use them.27,28 E-cigarettes could lead to an increase in nicotine use and dependence, and be a gateway to combustible tobacco products. Alternatively, e-cigarettes could lead to a reduction in combustible cigarette use among established smokers, potentially leading to incremental health benefits including decreased tobacco-related morbidity. Because nicotine is central to the lifelong addiction, and because these are nicotine delivery instruments, careful investigation and regulation of these products are required. At present, government and health advocates are charged with gate-keeping roles against the widespread use and adoption of e-cigarettes, and continuing the fight against nicotine addiction and the irresponsible behaviour of the tobacco industry. Many academic and professional societies, public health and government groups have published statements or policies opposing or restricting the use of e-cigarettes and/or have proposed its regulation as a medicinal product.26,29,30 E-cigarettes and other electronic products containing nicotine are to be regulated as medicines in the United Kingdom from 2016 onward.31 In the United States, sales, advertisement and use of e-cigarettes are permitted, but subject to variable degrees of restriction across different States. In the Asia-Pacific region, e-cigarettes are totally banned in Indonesia, Japan, Malaysia, Singapore, Taiwan and Thailand and classified as unlicensed medical products. In Australia and New Zealand, e-cigarettes are provided partial permission as long as they do not contain nicotine. The same applies to Hong Kong—e-cigarettes containing nicotine are classified as a pharmaceutical product requiring registration and their use as a smoking cessation tool is not recommended. In China, Korea and the Philippines, the sale and use of e-cigarettes is permitted, although they are considered tobacco products in Korea and are therefore subject to local tobacco control legislation. The APSR’s view is consistent with that of the FIRS Position Statement1—electronic nicotine delivery devices should be restricted or banned until more information about their safety is available. If electronic nicotine delivery devices are permitted, they should be regulated as medicines. If electronic nicotine delivery devices are not regulated as medicines, they should be regulated as tobacco products. The position statement is not limited to self-harm, and notes that research is required on the possible harmful effects of inhaling second-hand vapours from e-cigarettes.32 Such research, supported by sources other than the tobacco or e-cigarette industry, should be carried out to deterRespirology (2014) 19, 945–947
Editorial
mine the impact of electronic nicotine delivery devices on health in a wide variety of settings. All information derived from such research should be conveyed to the public in a clear manner. The joint statement by FIRS on e-cigarettes is fully supported by the ASPR. In brief, it notes that: 1 The increasing use of e-cigarettes represents a serious health concern that must not be neglected. 2 Such increasing use may represent its acceptance as a result of marketing and packaging strategies and statements, which may not be evidence based. 3 To date, the efficacy and safety of e-cigarettes in smoking cessation have not been substantiated. 4 E-cigarettes, most of which contain nicotine, could be as addictive as conventional cigarettes. 5 ENDS should be restricted or banned until their safety and efficacy are substantiated with clear and sound evidence. Such devices should be regulated the same way as for medicinal nicotine. 6 More research and clinical trials are required on the safety and efficacy of e-cigarettes for smoking cessation. Until there is further evidence to support their efficacy and safety for use both at an individual level or at the population level, e-cigarettes cannot be recommended for human consumption. The APSR and its official journal, Respirology, oppose smoking in any form, whether it be combustible tobacco cigarettes or e-cigarettes. David C.L. Lam, MBBS, PhD, FAPSR1 Arth Nana, MD, FAPSR2 and Peter R. Eastwood, PhD, FAPSR3 on behalf of the Asian-Pacific Society of Respirology (APSR) 1 Department of Medicine, University of Hong Kong, Hong Kong SAR, China 2 Division of Respiratory Disease and Tuberculosis, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand 3 Centre for Sleep Science, School of Anatomy, Physiology and Human Biology, University of Western Australia, Perth, Australia
REFERENCES 1 Schraufnagel DE, Blasi F, Drummond MB, Lam DC, Latif E, Rosen MJ, Sansores R, Van Zyl-Smit R, on behalf of the Forum of International Respiratory Societies. Electronic cigarettes: a position statement of the forum of international respiratory societies. Am. J. Respir. Crit. Care Med. 2014. doi: 10.1164/ rccm.201407-1198PP; [Epub ahead of print]. 2 Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco ’endgame. N. Engl. J. Med. 2014; 370: 293–5. 3 Davis B, Dang M, Kim J, Talbot P. Nicotine concentrations in electronic cigarette refill and do-it-yourself fluids. Nicotine Tob. Res. 2014. doi: 10.1093/ntr/ntu080; [Epub ahead of print]. 4 Etter JF, Zather E, Svensson S. Analysis of refill liquids for electronic cigarettes. Addiction 2013; 108: 1671–9. 5 Lam DC, Minna JD. How do we safely get people to stop smoking. Cancer Prev. Res. 2011; 4: 1724–7. 6 Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking-cessation: tool results from an online survey. Am. J. Prev. Med. 2011; 40: 472–5. © 2014 Asian Pacific Society of Respirology
Editorial 7 Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska-Czapla M, Rosik-Dulewska C, Havel C et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob. Control 2013; 23: 133–9. 8 Polosa R, Rodu B, Caponnetto P, Maglia M, Raciti C. A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm Reduct. J. 2013; 10: 19. 9 Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am. J. Public Health 2013; 103: 923–30. 10 Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, Walker N. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382: 1629–37. 11 Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the ‘e-cigarette’ in the USA. Tob. Control 2013; 22: 19–23. 12 Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. e-Cigarette awareness, use, and harm perceptions in US adults. Am. J. Public Health 2012; 102: 1758–66. 13 Agaku IT, Ayo-Yusuf OA, Vardavas CI, Connolly G. Predictors and patterns of cigarette and smokeless tobacco use among adolescents in 32 countries, 2007–2011. J. Adolesc. Health 2014; 54: 47–53. 14 Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study. JAMA Pediatr. 2014; 168: 610–17. 15 Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Intern. Med. 2014; 174: 812–13. 16 Leone A, Landini L. Vascular pathology from smoking: look at the microcirculation! Curr. Vasc. Pharmacol. 2013; 11: 524–30. 17 Hawkins BT, Abbruscato TJ, Egleton RD, Brown RC, Huber JD, Campos CR, Davis TP. Nicotine increases in vivo blood-brain barrier permeability and alters cerebral microvascular tight junction protein distribution. Brain Res. 2004; 1027: 48–58. 18 Rigotti NA. Smoking cessation in patients with respiratory disease: existing treatments and future directions. Lancet Respir. Med. 2013; 1: 241–50. 19 Warren GW, Singh AK. Nicotine and lung cancer. J. Carcinog. 2013; 12: 1. 20 Digard H, Proctor C, Kulasekaran A, Malmqvist U, Richter A. Determination of nicotine absorption from multiple tobacco products and nicotine gum. Nicotine Tob. Res. 2013; 15: 255–61. 21 Lim HB, Kim SH. Inhalation of e-cigarette cartridge solution aggravates allergen-induced airway inflammation and hyperresponsiveness in mice. Toxicol. Res. 2014; 30: 13–18.
© 2014 Asian Pacific Society of Respirology
947 22 Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest 2012; 141: 1400–6. 23 McCauley L, Markin C, Hosmer D. An unexpected consequence of electronic cigarette use. Chest 2012; 141: 1110–13. 24 Thota D, Latham E. Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor. J. Emerg. Med. 2014; 47: 15–17. 25 King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011. Nicotine Tob. Res. 2013; 15: 1623–7. 26 Bam TS, Bellew W, Berezhnova I, Jackson-Morris A, Jones A, Latif E, Molinari MA, Quan G, Singh RJ, Wisotzky M. Position statement on electronic cigarettes or electronic nicotine delivery systems. Int. J. Tuberc. Lung Dis. 2014; 18: 5–7. 27 Adkison SE, O’Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH, Cummings KM, McNeill A, Thrasher JF, Hammond D et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am. J. Prev. Med. 2013; 44: 207–15. 28 Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C, Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS ONE 2013; 8: e66317. 29 Jimenez Ruiz CA, Solano Reina S, de Granda Orive JI, Signes-Costa Minaya J, de Higes Martinez E, Riesco Miranda JA, Altet Gomez N, Lorza Blasco JJ, Barrueco Ferrero M, de Lucas Ramos P. The electronic cigarette. official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes. Arch. Bronconeumol. 2014; 50: 362–7. 30 Cummings KM, Dresler CM, Field JK, Fox J, Gritz ER, Hanna NH, Ikeda N, Jassem J, Mulshine JL, Peters MJ et al. E-cigarettes and cancer patients. J. Thorac. Oncol. 2014; 9: 438–41. 31 Torjesen I. E-cigarettes are to be regulated as medicines from 2016. BMJ 2013; 346: f3859. 32 Schmitt CL, Lee YO, Curry LE, Farrelly MC, Rogers T. Research support for effective state and community tobacco control programme response to electronic nicotine delivery systems. Tob. Control 2014; 23(Suppl. 3): iii54–7.
Respirology (2014) 19, 945–947
EDITORIAL
Electronic cigarettes: ‘Vaping’ has unproven benefits and potential harm Key words: electronic cigarette, electronic nicotine delivery system, nicotine, smoking cessation, tobacco smoking. Abbreviations: APSR, Asian Pacific Society of Respirology; e-cigarette, electronic cigarette; ENDS, electronic nicotine delivery systems; FIRS, Forum of International Respiratory Societies.
The rapid increase in awareness and usage of electronic cigarettes (e-cigarettes) has prompted the Forum of International Respiratory Societies (FIRS) to recently publish a position statement that strongly opposes the unregulated production and use of e-cigarettes.1 The statement has been jointly endorsed by the American College of Chest Physicians, American Thoracic Society, Asociación Latinoamericana de Tórax, Asian Pacific Society of Respirology (APSR), European Respiratory Society, International Union Against Tuberculosis and Lung Disease (The Union) and Pan African Thoracic Society. ‘Electronic cigarettes’ or ‘electronic nicotine delivery systems’ (ENDS) are devices that deliver to the lung a vapourized liquid usually containing nicotine and other chemicals. The act of ‘vaping’ has been portrayed as a non-tobacco mimic that smokers can use to reduce the amount of cigarette consumption, almost like a smoking cessation tool. The appeal to users and primary concern for health advocates is the delivery of nicotine, a highly addictive substance.2 E-cigarettes have been claimed by some manufacturers to contain a lesser amount or even no nicotine, tar or carcinogens, than combustible cigarettes. However, in the current climate of inadequate or absent regulation, there exists insufficient information to objectively evaluate these claims. Manufacturers of e-cigarettes have reported that each replacement cartridge typically contains between 6 and 24 mg of nicotine, thereby mimicking the usual amount in nicotine gum or patch. However, external testing has shown the nicotine content of cartridges to be highly variable with some refill cartridges containing 100 mg of nicotine per millilitre.3 The role and safety of e-cigarettes and electronic nicotine delivery devices as nicotine replacement therapy remain unknown. This contrasts markedly with standard nicotine replacement therapy,4 which appear in the forms of gum, transdermal patch or lozenges. Such delivery systems were approved by regulatory agencies only after extensive study, have been shown to be safe and provide a well-defined amount of nicotine appropriate to aid smoking cessation.5 © 2014 Asian Pacific Society of Respirology
UNPROVEN BENEFIT OF BEING AN ALTERNATIVE TO CONVENTIONAL CIGARETTES While some studies have shown that individuals who do not intend to quit smoking can reduce their intake of combustible cigarettes with e-cigarettes,6,7 other studies have failed to show superiority of e-cigarettes over nicotine replacement medicine or placebo for individuals trying to quit smoking.8 The addictive power of nicotine and its untoward effects should not be underestimated.9 The potential benefits of electronic nicotine delivery devices, including harm reduction and as an aid to smoking cessation, have not been well studied.9,10
POTENTIAL HARMFUL EFFECTS SHOULD NOT BE OVERLOOKED Both combustible and e-cigarettes pose health risks to consumers. Awareness and use of e-cigarettes continue to spread rapidly and extensively.11,12 A particularly worrisome phenomenon is the common use of e-cigarettes among women, those who are less educated and adolescents.13–15 It is possible, therefore, that the use of e-cigarettes in these groups may actually encourage, rather than discourage, tobacco smoking in adolescents.14,15 Any harm reduction of nicotine is likely outweighed by its harmful effects on cardiac, respiratory, metabolic and neurological functions.16–18 Further, nicotine is potentially carcinogenic,19 regardless of whether directly ingested or absorbed through inhalation or via the skin surface.20 Inhalation of vapour from e-cigarette cartridges has been shown to augment inflammatory changes in mouse airway21 and shortterm usage of e-cigarettes has been shown to adversely affect lung function.22 Case reports have documented the development of lipoid pneumonitis23 and eosinophilic pneumonitis24 after the use of e-cigarettes in previously healthy individuals.
PUBLIC HEALTH CONCERN A public health concern is that the use of these products may increase the risk of non-smokers developing nicotine dependence and current smokers maintaining their dependence.25 Increased use, especially Respirology (2014) 19, 945–947 doi: 10.1111/resp.12374
946 among youth, has raised serious concerns about the overall impact of e-cigarettes on public health.12 At the population level, it is possible that the availability of e-cigarettes may have an overall adverse impact by increasing initiation and reducing cessation of smoking.1,26 Results are conflicting with one study showing e-cigarette use to be associated with a greater reduction in cigarettes per day over time, compared with individuals who did not use them.10 However, another study showed that e-cigarette users were not more likely to quit smoking than those who did not use them.27,28 E-cigarettes could lead to an increase in nicotine use and dependence, and be a gateway to combustible tobacco products. Alternatively, e-cigarettes could lead to a reduction in combustible cigarette use among established smokers, potentially leading to incremental health benefits including decreased tobacco-related morbidity. Because nicotine is central to the lifelong addiction, and because these are nicotine delivery instruments, careful investigation and regulation of these products are required. At present, government and health advocates are charged with gate-keeping roles against the widespread use and adoption of e-cigarettes, and continuing the fight against nicotine addiction and the irresponsible behaviour of the tobacco industry. Many academic and professional societies, public health and government groups have published statements or policies opposing or restricting the use of e-cigarettes and/or have proposed its regulation as a medicinal product.26,29,30 E-cigarettes and other electronic products containing nicotine are to be regulated as medicines in the United Kingdom from 2016 onward.31 In the United States, sales, advertisement and use of e-cigarettes are permitted, but subject to variable degrees of restriction across different States. In the Asia-Pacific region, e-cigarettes are totally banned in Indonesia, Japan, Malaysia, Singapore, Taiwan and Thailand and classified as unlicensed medical products. In Australia and New Zealand, e-cigarettes are provided partial permission as long as they do not contain nicotine. The same applies to Hong Kong—e-cigarettes containing nicotine are classified as a pharmaceutical product requiring registration and their use as a smoking cessation tool is not recommended. In China, Korea and the Philippines, the sale and use of e-cigarettes is permitted, although they are considered tobacco products in Korea and are therefore subject to local tobacco control legislation. The APSR’s view is consistent with that of the FIRS Position Statement1—electronic nicotine delivery devices should be restricted or banned until more information about their safety is available. If electronic nicotine delivery devices are permitted, they should be regulated as medicines. If electronic nicotine delivery devices are not regulated as medicines, they should be regulated as tobacco products. The position statement is not limited to self-harm, and notes that research is required on the possible harmful effects of inhaling second-hand vapours from e-cigarettes.32 Such research, supported by sources other than the tobacco or e-cigarette industry, should be carried out to deterRespirology (2014) 19, 945–947
Editorial
mine the impact of electronic nicotine delivery devices on health in a wide variety of settings. All information derived from such research should be conveyed to the public in a clear manner. The joint statement by FIRS on e-cigarettes is fully supported by the ASPR. In brief, it notes that: 1 The increasing use of e-cigarettes represents a serious health concern that must not be neglected. 2 Such increasing use may represent its acceptance as a result of marketing and packaging strategies and statements, which may not be evidence based. 3 To date, the efficacy and safety of e-cigarettes in smoking cessation have not been substantiated. 4 E-cigarettes, most of which contain nicotine, could be as addictive as conventional cigarettes. 5 ENDS should be restricted or banned until their safety and efficacy are substantiated with clear and sound evidence. Such devices should be regulated the same way as for medicinal nicotine. 6 More research and clinical trials are required on the safety and efficacy of e-cigarettes for smoking cessation. Until there is further evidence to support their efficacy and safety for use both at an individual level or at the population level, e-cigarettes cannot be recommended for human consumption. The APSR and its official journal, Respirology, oppose smoking in any form, whether it be combustible tobacco cigarettes or e-cigarettes. David C.L. Lam, MBBS, PhD, FAPSR1 Arth Nana, MD, FAPSR2 and Peter R. Eastwood, PhD, FAPSR3 on behalf of the Asian-Pacific Society of Respirology (APSR) 1 Department of Medicine, University of Hong Kong, Hong Kong SAR, China 2 Division of Respiratory Disease and Tuberculosis, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand 3 Centre for Sleep Science, School of Anatomy, Physiology and Human Biology, University of Western Australia, Perth, Australia
REFERENCES 1 Schraufnagel DE, Blasi F, Drummond MB, Lam DC, Latif E, Rosen MJ, Sansores R, Van Zyl-Smit R, on behalf of the Forum of International Respiratory Societies. Electronic cigarettes: a position statement of the forum of international respiratory societies. Am. J. Respir. Crit. Care Med. 2014. doi: 10.1164/ rccm.201407-1198PP; [Epub ahead of print]. 2 Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco ’endgame. N. Engl. J. Med. 2014; 370: 293–5. 3 Davis B, Dang M, Kim J, Talbot P. Nicotine concentrations in electronic cigarette refill and do-it-yourself fluids. Nicotine Tob. Res. 2014. doi: 10.1093/ntr/ntu080; [Epub ahead of print]. 4 Etter JF, Zather E, Svensson S. Analysis of refill liquids for electronic cigarettes. Addiction 2013; 108: 1671–9. 5 Lam DC, Minna JD. How do we safely get people to stop smoking. Cancer Prev. Res. 2011; 4: 1724–7. 6 Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking-cessation: tool results from an online survey. Am. J. Prev. Med. 2011; 40: 472–5. © 2014 Asian Pacific Society of Respirology
Editorial 7 Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska-Czapla M, Rosik-Dulewska C, Havel C et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob. Control 2013; 23: 133–9. 8 Polosa R, Rodu B, Caponnetto P, Maglia M, Raciti C. A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm Reduct. J. 2013; 10: 19. 9 Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am. J. Public Health 2013; 103: 923–30. 10 Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, Walker N. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382: 1629–37. 11 Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the ‘e-cigarette’ in the USA. Tob. Control 2013; 22: 19–23. 12 Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. e-Cigarette awareness, use, and harm perceptions in US adults. Am. J. Public Health 2012; 102: 1758–66. 13 Agaku IT, Ayo-Yusuf OA, Vardavas CI, Connolly G. Predictors and patterns of cigarette and smokeless tobacco use among adolescents in 32 countries, 2007–2011. J. Adolesc. Health 2014; 54: 47–53. 14 Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study. JAMA Pediatr. 2014; 168: 610–17. 15 Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Intern. Med. 2014; 174: 812–13. 16 Leone A, Landini L. Vascular pathology from smoking: look at the microcirculation! Curr. Vasc. Pharmacol. 2013; 11: 524–30. 17 Hawkins BT, Abbruscato TJ, Egleton RD, Brown RC, Huber JD, Campos CR, Davis TP. Nicotine increases in vivo blood-brain barrier permeability and alters cerebral microvascular tight junction protein distribution. Brain Res. 2004; 1027: 48–58. 18 Rigotti NA. Smoking cessation in patients with respiratory disease: existing treatments and future directions. Lancet Respir. Med. 2013; 1: 241–50. 19 Warren GW, Singh AK. Nicotine and lung cancer. J. Carcinog. 2013; 12: 1. 20 Digard H, Proctor C, Kulasekaran A, Malmqvist U, Richter A. Determination of nicotine absorption from multiple tobacco products and nicotine gum. Nicotine Tob. Res. 2013; 15: 255–61. 21 Lim HB, Kim SH. Inhalation of e-cigarette cartridge solution aggravates allergen-induced airway inflammation and hyperresponsiveness in mice. Toxicol. Res. 2014; 30: 13–18.
© 2014 Asian Pacific Society of Respirology
947 22 Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest 2012; 141: 1400–6. 23 McCauley L, Markin C, Hosmer D. An unexpected consequence of electronic cigarette use. Chest 2012; 141: 1110–13. 24 Thota D, Latham E. Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor. J. Emerg. Med. 2014; 47: 15–17. 25 King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011. Nicotine Tob. Res. 2013; 15: 1623–7. 26 Bam TS, Bellew W, Berezhnova I, Jackson-Morris A, Jones A, Latif E, Molinari MA, Quan G, Singh RJ, Wisotzky M. Position statement on electronic cigarettes or electronic nicotine delivery systems. Int. J. Tuberc. Lung Dis. 2014; 18: 5–7. 27 Adkison SE, O’Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH, Cummings KM, McNeill A, Thrasher JF, Hammond D et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am. J. Prev. Med. 2013; 44: 207–15. 28 Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C, Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS ONE 2013; 8: e66317. 29 Jimenez Ruiz CA, Solano Reina S, de Granda Orive JI, Signes-Costa Minaya J, de Higes Martinez E, Riesco Miranda JA, Altet Gomez N, Lorza Blasco JJ, Barrueco Ferrero M, de Lucas Ramos P. The electronic cigarette. official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes. Arch. Bronconeumol. 2014; 50: 362–7. 30 Cummings KM, Dresler CM, Field JK, Fox J, Gritz ER, Hanna NH, Ikeda N, Jassem J, Mulshine JL, Peters MJ et al. E-cigarettes and cancer patients. J. Thorac. Oncol. 2014; 9: 438–41. 31 Torjesen I. E-cigarettes are to be regulated as medicines from 2016. BMJ 2013; 346: f3859. 32 Schmitt CL, Lee YO, Curry LE, Farrelly MC, Rogers T. Research support for effective state and community tobacco control programme response to electronic nicotine delivery systems. Tob. Control 2014; 23(Suppl. 3): iii54–7.
Respirology (2014) 19, 945–947
