Tobacco: E-cigarettes

Electronic cigarettes (or e-cigarettes) are the most common form of electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) but there are others, such as e-cigars and e-pipes. ENDS contain varying amounts of nicotine and harmful emissions.

E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users, and non-users who are exposed to the aerosols second-hand. Some products claiming to be nicotine-free (ENNDS) have been found to contain nicotine.

The consumption of nicotine in children and adolescents has deleterious impacts on brain development, leading to long-term consequences for brain development and potentially leading to learning and anxiety disorders.

Nicotine is highly addictive and some evidence suggest that never-smoker minors who use ENDS can double their chance of starting to smoke tobacco cigarettes later in life.

Evidence reveals that these products are harmful to health and are not safe. However, it is too early to provide a clear answer on the long-term impact of using them or being exposed to them. Some recent studies suggest that ENDS use can increase the risk of heart disease and lung disorders. Nicotine exposure in pregnant women can have similar consequences for the brain development of the fetus.

ENDS use can also expose non-smokers and bystanders to nicotine and other harmful chemicals.

Electronic delivery systems have also been linked to a number of physical injuries, including burns from explosions or malfunctions, when the products are not of the expected standard or are tampered with by users.

Accidental exposure of children to ENDS e-liquids pose serious risks as devices may leak, or children may swallow the poisonous e-liquid.

There is growing evidence that ENDS could be associated with lung injuries and in recent times e-cigarette and vaping have been linked to an outbreak of lung injury in the USA. This is described by the United States Centers for Disease Control and Prevention (CDC) as e-cigarette or vaping associated lung injury (EVALI), which led the CDC to activate an emergency investigation into EVALI on 17 September 2019.

The CDC notes, “As of 18 February 2020, there have been a total of 2,807 cases of EVALI reported from all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands, including 60 deaths confirmed in 27 states and the District of Columbia. While the cause of these deaths has not been conclusively determined, vitamin E acetate (VEA), a common additive in ENDS that contains cannabis (or THC), is thought to have played a significant role in these cases of lung injury. Further information on this incident, including a strong link of the EVALI outbreak to Vitamin E Acetate and the latest report, is available at https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html, which is updated every week, as the evidence is not sufficient to exclude the contribution of other chemicals.” 

Both tobacco products and ENDS pose risks to health.  The safest approach is not to use either.

The levels of risk associated with using ENDS or tobacco products are likely to depend on a range of factors, some relating to the products used and some to the individual user. Factors include product type and characteristics, how the products are used, including frequency of use, how the products are manufactured, who is using the product, and whether product characteristics are manipulated post-sale.

Toxicity is not the only factor in considering risk to an individual or a population from exposure to ENDS emissions. These factors may include the potential for abusing or manipulating the product, use by children and adolescents who otherwise would not have used cigarettes, simultaneous use with other tobacco products (dual or poly use) and children and adolescents going on to use smoked products following experimentation with ENDS.  Further, not all ENDS are the same and the risks to health may differ from one product to another, and from user to user.

Nicotine is highly addictive. A non-smoker who uses ENDS may become addicted to nicotine and find it difficult to stop using ENDS or become addicted to conventional tobacco products. 

The aerosols generated by ENDS typically raises the concentration of particulate matter in indoor environments and contain nicotine and other potentially toxic substances. ENDS emissions therefore pose potential risks to both users and non-users.

How a country approaches ENDS will depend on factors particular to its situation. ENDS are currently banned in over 30 countries worldwide. In others they are regulated as consumer products, as pharmaceutical products, as tobacco products, other categories or totally unregulated.

Where they are not banned, WHO recommends that ENDS be regulated.

Regulatory objectives include:

• Preventing initiation of ENDS use by non-smokers and children, such as by preventing or restricting advertising, promotion and sponsorship, and restricting flavours that appeal to children 
• Minimizing as far as possible potential health and/or risks to ENDS users, such as by regulating product characteristics
• Protecting non-users from exposure to their emissions, such as by prohibiting ENDS use in indoor spaces where smoking is not permitted
• Preventing unproven health claims
• Protecting public health policies from commercial and other vested interests
  

To date, evidence on the use of ENDS as a cessation aid is inconclusive. In part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear.

To truly help tobacco users quit and to strengthen global tobacco control, governments need to scale up policies and interventions that we know work. Tried and tested interventions, such as brief advice from health professionals, national toll-free quit lines and cessation interventions delivered via mobile text messaging are recommended. Where economically feasible, governments should also consider promoting nicotine replacement therapies and non-nicotine pharmacotherapies for cessation.

WHO regularly monitors and reviews the evidence on ENDS and health and offers guidance to governments.

This includes the biennial WHO Report on the Global Tobacco Epidemic, which tracks the status of the tobacco epidemic and interventions to combat it and other relevant resources. 

WHO strives to build a safer, healthier world for everyone, everywhere.

Links to WHO reports with further information on e-cigarettes or ENDS to which the reader can refer are provided below: 

• WHO report on the global tobacco epidemic, 2021. Geneva: World Health Organization, 2021
• Ghebreyesus TA. (2019). Progress in beating the tobacco epidemic. Lancet. (published online July 26)
• WHO Study Group on Tobacco Product Regulation. Report on the scientific basis of tobacco product regulation: seventh report of a WHO study group. Geneva: World Health Organization; 2019 (WHO Technical Report Series, No. 1015). Licence: CC BY-NC-SA 3.0 IGO
• FCTC/COP6 10 Rev 1 (2014) –WHO. Electronic nicotine delivery systems. Report by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, sixth session
• FCTC/COP7/11 (2016) - WHO. Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS). Report by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Seventh session