Tobacco: E-cigarettes

There are many different types of e-cigarettes, which are the most common type of electronic nicotine delivery system (ENDS) and electronic non-nicotine delivery system (ENNDS). These systems heat a liquid to create aerosols that are inhaled by the user. These so-called e-liquids may or may not contain nicotine (but do not contain tobacco). They also typically contain additives, flavours and chemicals that can be harmful to people’s health. E-cigarettes are part of broader products categories of ENDS and ENNDS, which include products such as e-cigars and e-pipes. WHO is concerned that these products have been allowed on the open market as consumer products and aggressively marketed to young people. Currently, 88 countries have no minimum age at which e-cigarettes can be bought and 74 countries have no regulations in place for these harmful products. E-cigarettes target children through social media and influencers, with at least 16 000 attractive flavours. Some of these products use cartoon characters and have sleek designs, which appeal to the younger generation. Some look like toys and games. There is an alarming increase in use of e-cigarettes among children and young people, with rates exceeding adult use in many countries. Even brief exposure to e-cigarette content on social media is associated with greater intention to use these products, as well as more positive attitudes toward e-cigarettes.

Are e-cigarettes dangerous?

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.

Nicotine exposure in pregnant women can adversely affect the development of the fetus. Further, the consumption of nicotine in children and adolescents has negative 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 harmful to health. Additionally, high quality epidemiology studies consistently demonstrate that e-cigarettes use increases conventional cigarette uptake, particularly among non-smoking youth, by nearly 3 times. 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. Whilst long-term health effects are not fully known, we do know that they generate toxic substances, some of which are known to cause cancer and some that increase the risk of heart and lung disorders. 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.

Do e-cigarettes (ENDS) cause lung injuries?

There is growing evidence that ENDS could be associated with lung injuries. E-cigarettes have also been linked to an episode of lung injury in the United States of America. 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 United States Centers for Disease Control and Prevention noted, “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 68 deaths confirmed in 29 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 here, which is updated every week, as the evidence is not sufficient to exclude the contribution of other chemicals.”

Are e-cigarettes more or less dangerous than conventional tobacco cigarettes?

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, user behaviour – user’s puffing style – 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. Dual use, which is common, is at least as dangerous and likely more dangerous than smoking conventional cigarettes or using e-cigarettes alone. Further, not all ENDS are the same and the risks to health may differ from one product to another, and from user to user.

Are ENDS addictive?

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. Further, many e-cigarettes are designed to allow the control of nicotine (which can reach dangerously high levels). This can also increase the levels of other toxicants to the user and also expose bystanders to harmful emissions.

Are second-hand ENDS emissions dangerous?

The aerosols generated by ENDS typically raise 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.

What are the policy options for regulating ENDS?

How a country approaches ENDS will depend on factors particular to its situation. ENDS are currently banned in about 35 countries worldwide. In others they are regulated as consumer products, as pharmaceutical products, as tobacco products, in other categories or totally unregulated.

The following are recommended:

where countries ban the sale of e-cigarettes, to strengthen implementation of the ban and continue monitoring and surveillance to support public health interventions and ensure strong enforcement; and
where countries permit commercialization (sale, importation, distribution and manufacture) of e-cigarettes as consumer products, to ensure strong regulations to reduce their appeal and their harm to the population, including banning all flavours, limiting the concentration and quality of nicotine, and taxing them.

WHO further recommends:

where countries pursue a smoking cessation strategy utilizing e-cigarettes, to carefully weigh national circumstances and the risk of uptake, and exhaust other proven cessation strategies. The conditions under which the products are accessed should be controlled to ensure appropriate clinical conditions and the products should be regulated as medicines, rather than their sale permitted as consumer products.

The tobacco industry profits from destroying health and is using these newer products to get a seat at the policy making table with governments to lobby against health policies. WHO is concerned that the tobacco industry funds and promotes false evidence to argue that these products reduce harm, while at the same time heavily promoting these products to children and non-smokers and continuing to sell billions of cigarettes.

What role do ENDS play in smoking cessation?

E-cigarettes as consumer products have not been proven to be effective for cessation at the population level. Instead, alarming evidence on adverse population health effects is mounting.

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 mobile and digital cessation services are recommended. Where economically feasible, governments should also consider promoting nicotine replacement therapies and non-nicotine pharmacotherapies for cessation.

What is WHO doing about ENDS?

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 stresses that Member States should implement a comprehensive approach to tobacco control which includes raising tobacco excise taxes, bans on tobacco advertising, promotion and sponsorship, health warnings, smoke-free areas, mass-media campaigns and supporting people to quit with proven tools such as advice from healthcare workers, toll-free quit lines, mobile and digital cessation services, and approved therapies.

Strong decisive action is needed to prevent the uptake of e-cigarettes based on the growing body of evidence of use by children and adolescents and health harms.

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

What further information is available?

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

WHO TEAM

No Tobacco (TFI)

News

Fact sheets

Feature stories