review article Use of Electronic Cigarettes Among Children and Adolescents
Saleha Shah*
Department of Dental Surgery Section, Faculty of Health Sciences, Medical College, The Aga Khan University Karachi, Pakistan
*Corresponding author: Saleha Shah,
Aga
Khan University Hospital, Karachi Stadium Road, P.O. Box 3500. Karachi 74800,
Pakistan Tel: +92 21 111-911-911. Fax: +92 21 3493 4294, 3493 2095. Email: marketing@aku.edu.
Received Date: 12 April, 2018; Accepted Date: 23 April, 2018; Published Date: 01 May, 2018
Citation: Shah S (2018) Use of Electronic Cigarettes Among Children and Adolescents. Clin Pharmacol Toxicol: ACPT-110. DOI: 10.29011/2577-0225. 000010
1. Abstract
Electronic
Nicotine Delivery Systems (ENDS) are handheld devices which produce an aerosol from
a solution containing nicotine, flavoring chemicals and propylene glycol for inhalation.
Nicotine being the major active ingredient in ENDS solutions is highly
addictive and toxic hence poses health risks to both users and nonusers. It is
the most common tobacco product among youth. The nicotine in ENDS solutions
poses a risk of poisoning children. Nonusers are involuntarily exposed to the
emissions of these devices with secondhand and third hand aerosol. The
marketing strategy with flavors and design appeals to youth and encourages nicotine
and tobacco product use. Hence it is important to institute regulation,
judicial act and discourage the use of ENDs for promoting health and safety of
young children.
1. Introduction
E-cigarette; an electronic nicotine delivery systems (ENDS); is a hand-held battery powered device with a heating element or an atomizer which converts nicotine-based solution (e liquid/ e juice) in a reservoir into vapor (aerosol) for inhalation via a mouthpiece through which the user puffs [1-3]. It is a way for stopping or reducing smoking and consuming in smoke-free places.
The vapor inhalation and exhaling is denoted as vaping [3]. Second hand aerosol is defined as an ENDS emission expired into the surrounding environment from both the device and lungs of the user. Third hand aerosol from ENDS persists on the surfaces and in the dust after the device is used and reemits into the gas phase or reaction with environmental oxidants as secondary pollutants. The alternate terms for END include e-cigarettes, electronic cigarettes, electronic cigars, e-cigs, e-cigars, cigalikes, e-hookah, electronic hookah, hookah sticks, mechanical mods, personal vaporizers, tank systems, vaping devices and vape pens. The differing terms are due to geographic regions or preferences among young users.
The
constituents of E-cigarette include nicotine in a base solution containing propylene
glycol, with/without glycerol, flavoring agents, anti-freeze, nickel, cadmium,
chromium and carcinogens like nitrosamines, each vial of 5ml E-cigarette refill
solution contains 20 mg/mL or 100 mg nicotine. The lethal dose of nicotine in
children is 10 mg and ranges between 30 and 60 mgs in adults [4]. Differences in the voltage of the battery and
circuit units result in a substantial variability in the ability of this
product to heat the solution to an aerosol and affect nicotine delivery
resulting in the formation of toxic emission [5].
The lithium-ion battery may explode and cause fire while charging.
An E- cigarette has a wide variety of designs but operates in a similar manner. They may appear as cigars, cigarettes, pipes, cigarillos, hookahs, pens, larger cylindrical or rectangular devices and USB sticks in over 460 different brands. They are sold by vendors, kiosks, vape shops, gas stations, grocery/convenience stores, pharmacies and internet vendors. First-generation” ENDS were similar to cigarettes but new model may resemble objects such as a pen or flashlight [6]. E-cigarette products can be used as a delivery system for cannabinoids and potentially for other illicit drugs. Nicotine stimulates the adrenal gland to release the hormone epinephrine (adrenaline) and increases the levels of dopamine which is a chemical messenger in the brain. This motivates some people to use nicotine repeatedly despite possible health risks during pregnancy for cardiovascular disease and deleterious effects on the developing brain [7]. Nicotine, neuroteratogen, crosses the placenta during pregnancy resulting in several adverse fetal consequences, including sudden infant death syndrome, deficits in auditory processing, altered corpus callosum and obesity. Nicotine may promote tumor [8] and malignant disease [9] by altering vital natural processes including cell proliferation, migration, apoptosis, invasion, inflammation, angiogenesis and cell-mediated immunity in fetal, embryonic stem cells, adult tissues, cancer cells and adult stem cells [10].
Exposure to nicotine during early CNS development leads to neuronal degeneration via altered neuron structure, neurotransmitter system function, nicotinic AChR expression and neurobehavioral development and premature cholinergic signaling pathway activation leads to brain discoordination [11]. Children, adolescents, women of reproductive age and pregnant women should hence be cautious with use of ENDS owing to long term consequences on brain development secondary to nicotine exposure [12]. Propylene glycol has the potential to cause throat eye and airway irritation [13] and asthma in children subsequent to long term exposure [14]. E-liquid can contaminate skin and lead to nicotine poisoning which manifests as sweating, dizziness, increased heart rate, vomiting, lethargy, difficulty in breathing and seizures [15].
E-cigarette is a less injurious alternative proposed for nicotine consumption in tobacco smokers [16-17] and tobacco-containing products [18-20]. At present the evidence regarding efficacy of ENDS as a modality for quitting tobacco smoking is mixed and inconclusive [21]. The aerosol exhaled contains lower toxic emission levels compared to combusted tobacco however these levels may be unacceptable by the exposed person considering that the exhaled aerosol may surge above acceptable levels of risk of disease such as when toxicant levels produced by ENDS and cigarettes is similar [22]. Evidence shows similar Serum levels of cotinine (a biomarker for exposure to tobacco smoke) in both secondhand cigarette smoke and e-cigarette vapors within one-hour exposure [23] and that the vapor of e- cigarettes contains toxic and potentially carcinogenic compounds [24-26].
A lack of e-cigarette marketing regulations allows the manufacturers to withhold information regarding the ingredients inhaled and exhaled by the user [1-28] thus risking young children [1]. A variety of e-cigarette solution flavors include peppermint, chocolate, piña colada candy, coffee, bubble gum, [29] coffee, tobacco unique flavors (Belgian waffle) and alcoholic drink flavors (e.g., strawberry daiquiri), even though they have been excluded in tobacco containing cigarettes [30-31].
Hence
it is necessary to regulate ENDS as a prerequisite for instituting a scientific
basis which allows the evaluation of the effects of their use and ensuring that
the public has up-to-date and dependable information regarding the potential benefits
and risks of consuming ENDS and to ensure that the public health is not
affected inadvertently [32]. Screening
for use and exposure of ENDS should be assimilated in the screening children
and adolescents for tobacco use and information regarding the harms of ENDS and
all nicotine containing products should be reiterated in addition to
highlighting the importance of remaining a nonuser of ENDS. ENDS should not be
endorsed as a treatment for tobacco dependence. Parents, caregivers, and
adolescents using ENDS should be referred for or provided tobacco cessation
counseling and tobacco dependence pharmacotherapies. A practitioner should be
able to recognize symptoms of acute nicotine poisoning and differentiate them
from symptoms of other unexplained etiologies.
2. Conclusion
E-cigarette used by young adults is a recent public health concern. It is important to understand use of e-cigarettes among young persons because this practice may transition into adulthood with unfavorable health consequences. E-cigarette is used with other combustible tobacco products. The use of such nicotine products endangers young children, fetuses, pregnant women and the developing brain. The limited current research pertaining to e-cigarettes compared with a multitude of research on cigarette smoking advocates the “precautionary principle” which proposes mediation for avoiding potential health risks which are still uncertain and incompletely defined. Action need to be taken to address e-cigarette use among youth and young adults at various regional levels like the territorial, tribal, local state or national levels. These arrangements may encompass preventing access to e-cigarettes, incorporating e-cigarettes into smoke free policies, revising tax and price policies, retail licensure, regulating marketing of e-cigarettes, set up surveillance to assess the use of drugs other than nicotine in e-cigarettes and initiate educational activities for young adults.
3. Future Recommendations
In the
current context of rising rates of e cigarette use by youth, policies and
programs need to be implemented and regulated in the future for minimizing harm
for both individuals and population at the local, state, and national levels. This
is instrumental for protecting youth and young adults and informing them about
the adverse consequences of initiating or continuing the use of
nicotine-containing products. Public health can be protected if the e-cigarette
manufacturers incorporate a few regulations. These include standardizing
products and restricting flavors, minimizing package sizes, proscribing
self-service displays, restrict promotion, marketing and advertising and bar
brand-name event sponsorship, make child-resistant packs, regulate nicotine
levels in products and include health warnings
Figure 1: Electronic
cigarette devices [33].
Figure 2: Components of an
electronic cigarette.
1.
American
Academy of Pediatrics Richmond Center. E Cigarettes (2015).
2.
World
Health Organization. Electronic nicotine delivery systems (2015).
6.
Grana R, Benowitz N,
Glantz SA (2014) E-cigarettes: a scientific review. Circulation 129: 1972-1986.
29.
Viking Vapor.
E Cig E Liquid, E Juice Flavors and Over 100 E Cigarette Flavors! 2015.
32.
WHO Framework
Convention on Tobacco Control 2008.
33. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. 2016.
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