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===Smoking cessation===
===Smoking cessation===
[[File:No Smoking.svg|right|thumb|A common reason people use the e-cigarette is to circumvent [[smoke-free laws]].]]
The [[World Health Organization]] (WHO) has stated that the efficacy of electronic cigarettes as an aid in smoking cessation has not been demonstrated. They recommend that "consumers should be strongly advised not to use" electronic cigarettes until a reputable national regulatory body has found them safe and effective.<ref name="WHO2013"/>
The [[World Health Organization]] (WHO) has stated that the efficacy of electronic cigarettes as an aid in smoking cessation has not been demonstrated. They recommend that "consumers should be strongly advised not to use" electronic cigarettes until a reputable national regulatory body has found them safe and effective.<ref name="WHO2013"/>


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A 2013 randomized controlled trial found no difference in smoking cessation rates between e-cigarettes with nicotine, e-cigarettes without nicotine and traditional NRT patches.<ref name="Polosa2013">{{citation|first=Riccardo |last=Polosa|first2=Brad|last2=Rodu|author3-first=Pasquale|author3-last=Caponnetto|author4-first=Marilena |author4-last=Maglia|author5-first=Cirino |author5-last=Raciti|journal=Harm Reduction Journal| volume=10|issue=10|title=A fresh look at tobacco harm reduction: the case for the electronic cigarette |year=2013|url=http://www.biomedcentral.com/content/pdf/1477-7517-10-19.pdf|pmid=24090432|doi=10.1186/1477-7517-10-19}}</ref> There are some [[non-controlled studies]] that reported possible benefit.<ref>{{Cite journal | url=http://archest.fsm.it/pne/pdf/79/01/pne79-1-04-caponnetto-polosa.pdf | last1 = Caponnetto | first1 = P. | last2 = Russo | first2 = C. | last3 = Bruno | first3 = CM. | last4 = Alamo |first4 = A. | last5 = Amaradio | first5 = MD. | last6 = Polosa | first6 = R. | title = Electronic cigarette: a possible substitute for cigarette dependence | journal = Monaldi Arch Chest Dis | volume = 79 | issue = 1 | pages = 12–9 |date=Mar 2013 | doi = | pmid = 23741941 }}</ref>
A 2013 randomized controlled trial found no difference in smoking cessation rates between e-cigarettes with nicotine, e-cigarettes without nicotine and traditional NRT patches.<ref name="Polosa2013">{{citation|first=Riccardo |last=Polosa|first2=Brad|last2=Rodu|author3-first=Pasquale|author3-last=Caponnetto|author4-first=Marilena |author4-last=Maglia|author5-first=Cirino |author5-last=Raciti|journal=Harm Reduction Journal| volume=10|issue=10|title=A fresh look at tobacco harm reduction: the case for the electronic cigarette |year=2013|url=http://www.biomedcentral.com/content/pdf/1477-7517-10-19.pdf|pmid=24090432|doi=10.1186/1477-7517-10-19}}</ref> There are some [[non-controlled studies]] that reported possible benefit.<ref>{{Cite journal | url=http://archest.fsm.it/pne/pdf/79/01/pne79-1-04-caponnetto-polosa.pdf | last1 = Caponnetto | first1 = P. | last2 = Russo | first2 = C. | last3 = Bruno | first3 = CM. | last4 = Alamo |first4 = A. | last5 = Amaradio | first5 = MD. | last6 = Polosa | first6 = R. | title = Electronic cigarette: a possible substitute for cigarette dependence | journal = Monaldi Arch Chest Dis | volume = 79 | issue = 1 | pages = 12–9 |date=Mar 2013 | doi = | pmid = 23741941 }}</ref>


Electronic cigarettes were not regularly associated with trying to quit tobacco among young people.<ref name=Car2014/> Adults most often used electronic cigarettes as a replacement for tobacco, although not invariably to quit.<ref name=Car2014/>
Electronic cigarettes were not regularly associated with trying to quit tobacco among young people.<ref name=Car2014/> Adults most often used electronic cigarettes as a replacement for tobacco, although not invariably to quit.<ref name=Car2014/> Although some people have a desire to quit smoking by using e-cigarettes, other common explanations for the use of these products are to evade [[smoke-free laws]] and to cut back on traditional cigarettes, which may reinforce delaying or deterring to quit smoking.[http://circ.ahajournals.org/content/129/19/1972.full]


===Safety===
===Safety===
Electronic cigarettes should have fewer toxic effects than traditional cigarettes,<ref name=O2012>{{cite journal|last=O'Connor|first=RJ|title=Non-cigarette tobacco products: what have we learnt and where are we headed?|journal=Tobacco control|date=March 2012|volume=21|issue=2|pages=181–90|pmid=22345243|doi=10.1136/tobaccocontrol-2011-050281|pmc=3716250}}</ref><ref>{{cite book|last=Kufe|first=Donald W.|title=Holland-Frei cancer medicine.|year=2009|publisher=McGraw-Hill Medical|location=New York|isbn=9781607950141|page=395|url=http://books.google.com/books?id=R0FbhLsWHBEC&pg=PA395|edition=8th}}</ref> and evidence suggests they are safer than real cigarettes, and possibly as safe as other [[nicotine replacement products]].<ref name=Cahn2011/>
Electronic cigarettes should have fewer toxic effects than traditional cigarettes,<ref name=O2012>{{cite journal|last=O'Connor|first=RJ|title=Non-cigarette tobacco products: what have we learnt and where are we headed?|journal=Tobacco control|date=March 2012|volume=21|issue=2|pages=181–90|pmid=22345243|doi=10.1136/tobaccocontrol-2011-050281|pmc=3716250}}</ref><ref>{{cite book|last=Kufe|first=Donald W.|title=Holland-Frei cancer medicine.|year=2009|publisher=McGraw-Hill Medical|location=New York|isbn=9781607950141|page=395|url=http://books.google.com/books?id=R0FbhLsWHBEC&pg=PA395|edition=8th}}</ref> and evidence suggests they are safer than real cigarettes, and possibly as safe as other [[nicotine replacement products]].<ref name=Cahn2011/> The FDA has received voluntary reports of [[adverse event]]s involving e-cigarettes which include hospitalization for illnesses such as pneumonia, congestive heart failure, disorientation, seizure, hypotension, and other health problems but it is unknown whether e-cigarettes caused these adverse events.[http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm]


In an interview, the director of the Office on Smoking and Health for the U.S. federal agency [[Centers for Disease Control and Prevention]] (CDC) states that there is enough evidence to say that switching to electronic cigarettes would likely be healthier than smoking. However, due to the lack of regulation of the contents of the numerous different brands of electronic cigarettes and the presence of nicotine, which is not a benign substance, the CDC has issued warnings.<ref name = "CDC Q&A" />
In an interview, the director of the Office on Smoking and Health for the U.S. federal agency [[Centers for Disease Control and Prevention]] (CDC) states that there is enough evidence to say that switching to electronic cigarettes would likely be healthier than smoking. However, due to the lack of regulation of the contents of the numerous different brands of electronic cigarettes and the presence of nicotine, which is not a benign substance, the CDC has issued warnings.<ref name = "CDC Q&A" />

Revision as of 02:04, 20 May 2014

First generation electronic cigarette resembling a tobacco cigarette
Second generation types of electronic cigarettes

An electronic cigarette (e-cig or e-cigarette), personal vaporizer (PV) or electronic nicotine delivery system (ENDS) is a battery-powered device which simulates tobacco smoking by producing a vapor that resembles smoke. It generally uses a heating element known as an atomizer, that vaporizes a liquid solution. Some solutions contain a mixture of nicotine and flavorings, while others release a flavored vapor without nicotine.[citation needed]

First generation electronic cigarettes were usually designed to simulate smoking implements, such as cigarettes or cigars, in their use and appearance.[1] They produced less vapor than second generation personal vaporizers since they use smaller batteries.[1] New generation electronic cigarettes have an increased nicotine-dispersal performance,[citation needed] housing higher capacity batteries,[2] and come in various form factors, including metal tubes and boxes.[2][3][4]

The benefits and risks of electronic cigarette use are uncertain.[5][6] They carry a risk of nicotine addiction,[6] and their regulation is the subject of ongoing debate.[7] There are concerns that these products should be adequately regulated, mainly to protect users, while avoiding unintended consequences caused by excessive or inappropriate regulation.[7] Most people who use electronic cigarettes have a history of smoking cigarettes while some young people who have never smoked cigarettes have tried electronic cigarettes at least once.[8] The frequency of use has increased with up to 10% of American high school students having ever used them as of 2012 and around 3.4% of American adults as of 2011.[8]

A "smokeless non-tobacco cigarette" was patented in 1963 by Herbert A. Gilbert, which drew moistened air through a heating element.[9] Hon Lik invented an e-cigarette using piezoelectric components in 2003.[10] Because of the relative novelty of the technology and the possible relationship to tobacco laws and medical drug policies, electronic cigarette legislation and public health investigations are currently pending in many countries.[11] Current regulations vary widely, from regions with no regulations to others banning the devices entirely.[11]

Health

Smoking cessation

A common reason people use the e-cigarette is to circumvent smoke-free laws.

The World Health Organization (WHO) has stated that the efficacy of electronic cigarettes as an aid in smoking cessation has not been demonstrated. They recommend that "consumers should be strongly advised not to use" electronic cigarettes until a reputable national regulatory body has found them safe and effective.[6]

A 2011 review says that electronic cigarettes may aid in smoking cessation and are likely to be more effective than traditional pharmacotherapy, as the physical stimuli of holding and puffing on the electronic cigarette may be better at reducing short-term cravings.[12] The review found no studies that directly measured the effectiveness of electronic cigarettes in smoking cessation, and examined two published studies that indirectly considered the issue by measuring the effect of the product on cravings and other short-term indicators.[12] Another review felt that they may be a reasonable substitute for cigarette smoking.[7]

The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and chewing tobacco for long term use instead of smoking.[13]

The British Medical Association (BMA) reports there is a possibility for smoking cessation benefits, but has concerns that e-cigarettes are less regulated than nicotine replacement therapy (NRT), and that there is no peer reviewed evidence of their safety or efficacy. They recommend a "strong regulatory framework" for e-cigarette distribution in order to ensure their safety, quality, and that their marketing and sales are restricted to adults. The BMA encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue those methods, they say health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.[14]

One review found electronic systems appear to generally deliver less nicotine than smoking, raising the question of whether they can effectively substitute for tobacco smoking over a long-term period.[15]

A 2013 randomized controlled trial found no difference in smoking cessation rates between e-cigarettes with nicotine, e-cigarettes without nicotine and traditional NRT patches.[16] There are some non-controlled studies that reported possible benefit.[17]

Electronic cigarettes were not regularly associated with trying to quit tobacco among young people.[8] Adults most often used electronic cigarettes as a replacement for tobacco, although not invariably to quit.[8] Although some people have a desire to quit smoking by using e-cigarettes, other common explanations for the use of these products are to evade smoke-free laws and to cut back on traditional cigarettes, which may reinforce delaying or deterring to quit smoking.[2]

Safety

Electronic cigarettes should have fewer toxic effects than traditional cigarettes,[15][18] and evidence suggests they are safer than real cigarettes, and possibly as safe as other nicotine replacement products.[12] The FDA has received voluntary reports of adverse events involving e-cigarettes which include hospitalization for illnesses such as pneumonia, congestive heart failure, disorientation, seizure, hypotension, and other health problems but it is unknown whether e-cigarettes caused these adverse events.[3]

In an interview, the director of the Office on Smoking and Health for the U.S. federal agency Centers for Disease Control and Prevention (CDC) states that there is enough evidence to say that switching to electronic cigarettes would likely be healthier than smoking. However, due to the lack of regulation of the contents of the numerous different brands of electronic cigarettes and the presence of nicotine, which is not a benign substance, the CDC has issued warnings.[19]

One review raised concerns about the lack of regulatory oversight over the manufacturing process, marketing, and quality control. Also of concern were the purity of ingredients as well as the ease with which these devices can be modified.[15]

The BMA has noted literature finding electronic cigarettes as safer than tobacco smoking, but also is concerned by the lack of high quality peer-reviewed studies about safety. They have noted that the amount of nicotine delivered can be highly variable between devices due to differences in how well the nicotine is vaporized. They have also raised concerns that the delivered dose may be inconsistent or misleading compared to the nicotine level stated on the liquid container, with identically labelled cartridges emitting "markedly different" levels of nicotine. Issues around proper labeling, child-proof packaging, and electrical safety have also been raised.[14]

A preliminary analysis of e-cigarette cartridges by the US Food and Drug Administration (FDA) in 2009 identified that some contain tobacco-specific nitrosamines (TSNAs), known cancer-causing agents.[20][21] The amounts of TSNAs present were on par with existing NRT products like nicotine gum and inhalers. The FDA's analysis also detected diethylene glycol, a poisonous and hygroscopic liquid, in a single cartridge manufactured by Smoking Everywhere and nicotine in one[22] cartridge claimed to be nicotine-free.[20][21] Diethylene glycol was found in a cartridge tested in 2009 by the FDA, but in 2011 researchers reviewed the data and noted that 15 other studies had failed to find any evidence of this chemical in e-cigarettes.[23] Further concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device.[22] In some e-cigarettes, "Tobacco-specific impurities suspected of being harmful to humans – anabasine, myosmine, and β-nicotyrine – were detected in a majority of the samples tested." It is not clear if these chemicals were detectable in exhaled vapour.[24] The UK National Health Service noted that the toxic chemicals found by the FDA were at levels one-thousandth that of cigarette smoke, and that while there is no certainty that these small traces are harmless, initial test results are reassuring.[25]

Addiction

A number of organizations including the Centers for Disease Control and Prevention,[19] the International Union Against Tuberculosis and Lung Disease,[26] the American Academy of Pediatrics[27] and the Food and Drug Administration[28] have concerns that e-cigarettes might increase addiction to and use of nicotine and tobacco products in children.[29][30] The World Health Organization raises the concern of addiction for nonsmokers from their use.[31]

Construction

Disassembled cigarette-styled electronic cigarette.
A. LED light cover
B. battery (also houses circuitry)
C. atomizer (heating element)
D. cartridge (mouthpiece)
Battery connected to a USB charger

Most electronic cigarettes take an overall cylindrical shape although a wide array of shapes can be found: box, pipe styles etc. Many are made to look like tobacco cigarettes. Common components include a liquid delivery and container system, an atomizer, and a power source.[32] Many electronic cigarettes are composed of streamlined replaceable parts, while disposable devices combine all components into a single part that is discarded when its liquid is depleted.[33]

Atomizer

Along with the battery, the atomizer is the central component of every personal vaporizer. Although many kinds of atomizers are in use, they generally consist of a small heating element responsible for vaporizing liquid, as well as a wicking material that draws liquid in.

A small length of resistance wire is wrapped around the wicking material and then connected to the positive and negative poles of the device. When activated the resistance wire (or coil) quickly heats up thus turning the liquid into a vapor, which is then inhaled by the user.[34]

The electrical resistance of the coil, the voltage output of the device, the airflow of the atomizer and the efficiency of the wick play important roles in the perceived quality of the vapor that is produced by an atomizer. They also greatly affect the quantity or volume of vapor that will be produced by the atomizer.

Atomizer resistances usually vary from 1.5Ω (ohms) to 3.0Ω from one atomizer to the next but can go as low as 0.1Ω in the most extreme cases of DIY coil building which produce large amounts of vapor but could present a fire hazard and other dangerous battery failures if the user is not knowledgeable enough about basic electrical principles and how they relate to battery safety.[35][36]

Wicking materials vary greatly from one atomizer to another but silica fibers are the most commonly used in manufactured atomizers. "Rebuildable" or "do it yourself" atomizers can use silica, cotton, porous ceramic, hemp, bamboo yarn, oxidized stainless steel mesh and even wire rope cables as wicking materials.[37]

A wide array of atomizers and e-liquid container combinations are available:[38]

Cartomizers

Most of the devices that imitate the cigarette form factor use a "cartomizer" (a portmanteau of cartridge and atomizer) or "carto" as an e-liquid delivery system. The piece consists of a heating element surrounded by a liquid-soaked poly-foam that acts as an e-liquid holder. It is usually disposed of once the e-liquid acquires a burnt taste, which is usually due to an activation when the coil is dry or when the cartomizer gets consistently flooded (gurgling) because of sedimentation of the wick. Most cartomizers are refillable even if not advertised as such.[39]

Cartomizers can be used on their own or in conjunction with a tank that allows more e-liquid capacity. In this case the portmanteau word of "cartotank" has been coined. When used in a tank, the cartomizer is inserted in a plastic, glass or metal tube and holes or slots have to be punched on the sides of the cartomizer to allow liquid to reach the coil.

Clearomizers

eGo style e-cigarette with a top-coil clearomizer. Silica fibers are hanging down freely inside of the tank, drawing e-liquid by capillary action to the coil that is located directly under the mouthpiece.

Clearomizers or "clearos", not unlike cartotanks, use a clear tank in which an atomizer is inserted.[40] Unlike cartotanks, however, no poly-foam material can be found in them. There are a lot of different wicking systems employed inside of clearomizers to ensure good moistening of the wick without flooding the coil. Some rely on gravity to bring the e-liquid to the wick and coil assembly (bottom coil clearomizers for example) whereas others rely on capillary action and to some degree the user agitating the e-liquid while handling the clearomizer (top coil clearomizers).[41]

Rebuildable Atomizers

A rebuildable atomizer or an RBA is an atomizer that allows the user to assemble or "build" the wick and coil themselves instead of replacing them by an off-the-shelf atomizer "head". They also allow the user to build atomizers at any desired electrical resistance. The materials needed to "rebuild" the atomizers are usually much cheaper than the usual prefabricated replaceable wick and coil assemblies destined to clearomizers.

These atomizers are divided into two main categories; rebuildable tank atomizers (RTA's) and rebuildable dripping atomizers (RDA's).

Rebuildable tank atomizers or RTA's are similar to clearomizers in that they use a tank or container to hold and bring liquid to the coil. They usually hold a lot more e-liquid than their RDA counterparts.

Rebuildable dripping atomizers or RDA's on the other hand lack the container section and hold very little liquid compared to RTA's but are usually a lot smaller. They usually consist only of an atomizer "building deck" which can accept one or more coils and a "top cap" to cover the coils where a mouth piece can be attached. The user needs to manually keep the atomizer wet by dripping liquid on the bare wick and coil assembly, hence their name.

Power

Most portable devices contain a rechargeable battery, which tends to be the largest component of an electronic cigarette. The battery may contain an electronic airflow sensor whereby activation is triggered simply by drawing breath through the device, while other models employ a power button that must be held during operation. An LED to indicate activation may also be employed. Some manufacturers also offer a cigarette pack-shaped portable charging case (PCC), which contains a larger battery capable of charging e-cigarettes. Devices aimed at more experienced users may sport additional features, such as variable power output and support of a wide range of internal batteries and atomizer configurations,t and tend to stray away from the cigarette form factor. Some cheaper recent devices use an electret microphone with a custom IC to detect airflow and indicate battery status on the included blue LED.[42][failed verification]

Variable power and voltage devices

PV with variable and regulated power offering battery protection

Variable voltage or power personal vaporizers are devices that contain a built in electronic chip that allows the user to adjust the power that goes through the heating element. They usually incorporate a LED screen to display various information. Variable PV's eliminate the need of having to replace an atomizer with another one of lower or higher electrical resistance to change the intensity of the vapor.[43] They also feature voltage regulation and some battery protection.[44][45]

Some of these devices offer additional features through their menu system such as: atomizer resistance checker, remaining battery voltage, puff counter, activation cut-off etc.[46]

Mechanical personal vaporizers

Mechanical PV with a rebuildable atomizer

Mechanical PVs or mechanical "mods", often called "mechs" are devices without electronic components and battery protection (apart from vent holes drilled in some mechanical devices) or electric regulation. Because there is neither protection nor regulation, they will work either way the battery is inserted. They are activated by spring loaded or opposing magnetic mechanical switches, hence their name. They rely entirely on the natural voltage output of a battery.[citation needed]

They are commonly used with "low resistance" (1.0Ω ~ 0.2Ω) rebuildable atomizers. Seeing that most e-cigarettes containing electronic battery protection will interpret sub ohm resistance coils as a short circuit, thus prohibiting the device from being activated, mechanical mods are among the only devices that will accept such atomizer resistances although more recent (2013) electronic devices offers this possibility as well[citation needed]

Since mechanical PVs are unregulated and unprotected, they require special attention on the user's part that other regulated and protected PVs do not need. Making sure that the battery does not over-discharge and that the atomizer will not require more amperage than what the battery can safely allow are the user's responsibilities.[citation needed]

Liquid

Liquid for producing vapor in electronic cigarettes, commonly known as e-juice or e-liquid, is a solution of propylene glycol (PG), vegetable glycerin (VG), and/or polyethylene glycol 400 (PEG400) mixed with concentrated flavors; and optionally, a variable concentration of nicotine.[47]

The solution is often sold in a bottle or in pre-filled disposable cartridges. They are manufactured with various tobacco, fruit, and other flavors, as well as variable nicotine concentrations (including nicotine-free versions). The standard notation "mg/ml" is often used in labeling for denoting nicotine concentration, and is sometimes shortened to a simple "mg".[48]

Usage statistics

Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012.[47] As of 2011, in the United States, one in five adults who smoke have tried electronic cigarettes.[49] In a UK survey conducted in 2013 of more than 12,000 adults, 11% of regular smokers in the sample identified themselves as using electronic cigarettes and 24% stated that they had used them in the past. Amongst those who had never smoked in the same sample, 1% said they had tried them and 0% stated that they were currently using them.[50]

Among grade 6 to 12 students in the United States, those who have ever used the product increased from 3.3% in 2011 to 6.8% in 2012.[51] Those currently using electronic cigarettes increased from 0.6% to 1.1%. Over the same period the percentage of grade 6 to 12 students who regularly smoke tobacco cigarettes fell from 7.5% to 6.7%.[52] 10% of students who have used e-cigarettes at least once have never smoked.[51] A 2013 UK survey by Action on Smoking and Health found that among non-smokers under 18, 1% reported having tried e-cigarettes "once or twice," 0% reported continuing use, and 0% intended to try them in the future. ASH concluded that among children who have heard of e-cigarettes, sustained use is rare and confined to children who smoke or have smoked.[50]

A February 2014 survey by the French Monitoring Centre for Drugs and Drug Addiction of 2052 individuals estimated that between 7.7 and 9.2 million individuals have experimented with using electronic cigarettes, with between 1.1 and 1.9 million using on a daily basis. 67% of tobacco smokers in the survey used electronic cigarettes to reduce or quit tobacco smoking. 9% of those who experimented with electronic cigarettes had never smoked tobacco. Of the 1.2% that had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited electronic cigarettes for stopping tobacco use.[53]

Culture

As the electronic cigarette industry grows, a subculture has emerged which calls itself "the vaping community".[38][54][55] Members of this emerging subculture often view electronic cigarettes as a safer alternative to smoking and some even view it as a hobby. They tend to use highly customized devices that do not resemble what are known, by some, as "cig-a-likes," or electronic cigarettes that resemble real cigarettes.[56] Well known celebrities have also embraced this new found culture by taking their electronic cigarettes to public events such as movie award shows and press conferences.[57]

History

The earliest electronic cigarette can be traced to Herbert A. Gilbert,[58] who in 1963 patented a device described as "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air." This device heated the nicotine solution and produced steam. In 1967, Gilbert was approached by several companies interested in manufacturing it, but it was never commercialized and disappeared from the public record after 1967.[59][60][61][62][63][64]

Hon Lik, a Chinese pharmacist, is credited with the invention of the electronic cigarette.[10][65] In 2003,[66] he came up with the idea of using a piezoelectric ultrasound-emitting element to vaporise a pressurized jet of liquid containing nicotine diluted in a propylene glycol solution.[67] This design produces a smoke-like vapour that can be inhaled and provides a vehicle for nicotine delivery into the bloodstream via the lungs. He also proposed using propylene glycol to dilute nicotine and placing it in a disposable plastic cartridge which serves as a liquid reservoir and mouthpiece.

Electronic cigarettes using a different design were first introduced to the Chinese domestic market in May 2004 as an aid for smoking cessation and replacement. The company that Hon Lik worked for, Golden Dragon Holdings, changed its name to Ruyan (如烟, literally "Resembling smoking"), and started exporting its products in 2005–2006[68] before receiving its first international patent in 2007.[69]

The electronic cigarette continued to evolve from the first generation three-part device. In 2006 the "cartomizer" was invented by British entrepreneurs Umer and Tariq Sheikh of XL Distributors.[70] This is a mechanism which integrates the heating coil into the liquid chamber. The new device was launched in the UK in 2007 in their Gamucci brand and is now widely adopted by the majority of 'cigalike' brands. The grant of the UK patent for the "cartomizer" was made to XL Distributors in February 2013 and published by the UK Intellectual Property Office.[71]

The international tobacco companies, recognising the development of a potential new market sector that could render traditional tobacco products obsolete,[72] are increasingly involved in the production and marketing of their own brands of e-cigarettes and in acquiring existing e-cigarette companies.[73] Blu, a prominent US e-cigarette producer, was acquired by Lorillard Inc. in 2012.[74] British American Tobacco launched Vype in 2013, while Imperial Tobacco's Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite for $US 75 million in 2013 and launched Puritane in partnership with Boots UK.[75][76] On 3 February 2014, Altria Group, Inc. acquired popular electronic cigarette brand Green Smoke for $110 million. The deal is expected to be finalized during the second quarter of 2014.[77] Altria also markets its own e-cigarette, the MarkTen, while Reynolds American has entered the sector with its Vuse product.[78]

Because of the relative novelty of the technology and the possible relationship to tobacco laws and medical drug policies, electronic cigarette legislation and public health investigations are currently pending in many countries. Current regulations vary widely, from regions with no regulations to others banning the devices entirely.[11]

Europe

On 19 December 2012 the European Commission adopted its proposal to revise the European Union Tobacco Products Directive 2001/37/EC which included proposals to introduce restrictions on the use and sales of e-cigarettes.[79][80][81] On 8 October 2013 the European Parliament in Strasbourg voted down the Commission's proposal to introduce medical regulation for electronic cigarettes, but proposed that cross-border marketing of e-cigarettes be regulated similarly to tobacco products, meaning that sales of e-cigarettes to under 18s would be prohibited in the European Union, along with most cross-border advertising. Warning labels also would be required. The Parliament and Member States are involved in trilogue discussions to reach a common conclusion.[82]

  • In Austria nicotine-containing cartridges are classified as medicinal products and e-cigarettes for nicotine inhalation as medical devices.[83]
  • In Bulgaria, the sale and use of electronic cigarettes are legal, as well as the sale of cartridges and liquids with nicotine. There are no specific regulations from EU.[84]
  • In the Czech Republic, the use, sale and advertising of electronic cigarettes are legal.[85]
  • In Denmark, the Danish Medicines Agency classifies electronic cigarettes containing nicotine as medicinal products. Thus, authorization is required before the product may be marketed and sold, and no such authorization has currently been given. The agency has clarified, however, that electronic cigarettes that do not administer nicotine to the user, and are not otherwise used for the prevention or treatment of disease, are not considered medicinal devices.[86]
  • In Estonia, the Estonian State Agency of Medicines had previously banned e-cigarettes, but the ban was overturned in court on 7 March 2013.[87] Currently e-liquids containing more than 0.7 mg/ml of nicotine are still considered medicine and as such cannot be legally purchased within the country due to no manufacturer being licensed properly. Following the outcome of EU tobacco directive in October 2013, the legislation is moving towards a more relaxed stance on the issue. As stated by the Estonian minister of social affairs Taavi Rõivas (in charge of tobacco regulation), e-cigarettes will receive an advertisement ban and will clearly be banned for minors but will be available for adults before the end of 2013.
  • In Finland, the National Supervisory Authority of Welfare and Health (Valvira) declared that the new tobacco marketing ban (effective 1 January 2012) will also cover electronic cigarettes,[88] resulting in that Finnish stores or webstores can't advertise e-cigarettes because they might look like regular cigarettes. In theory, e-cigarettes with nicotine-free cartridges may still be sold, as long as their images and prices are not visible. Ordering from abroad remains allowed. Sale of nicotine cartridges is currently prohibited, as nicotine is considered a prescription drug requiring an authorization that such cartridges do not yet have. However, the Finnish authorities have decided that nicotine cartridges containing less than 10 mg nicotine, and e-liquid containing less than 0,42 g nicotine per bottle, may be legally brought in from other countries for private use. If the nicotine content is higher, a prescription from a Finnish physician is required. From a country within the European Economic Area a maximum of one year's supply may be brought in for private use when returning to Finland, while three months' supply may be brought in from outside the EEA. Mail order deliveries from EEA countries, for a maximum of three months' supply, are also allowed.[89][90]
  • In Germany, the sale and use of electronic cigarettes are legal.[91]
  • In Hungary, the sale and use of electronic cigarettes are legal. The sale of cartridges and liquids with nicotine is illegal.
  • In Ireland, the sale and use of electronic cigarettes are legal.[85]
  • In Italy, by a Health Ministry decree (G.U. Serie Generale, n. 248 del 23 ottobre 2012) electronic cigarettes containing nicotine cannot be sold to individuals under 16 years of age.[92]
  • In Latvia, e-cigarettes are legal.[93]
  • In Lithuania, e-cigarettes are legal.[93]
  • In the Netherlands, use and sale of electronic cigarettes is allowed, advertising is restricted.[85]
  • In Norway the sale and use of electronic cigarettes are legal,[85] but nicotine cartridges can only be imported from other EEA member states (e.g. the UK) for private use.[94]
  • In Poland, the sale and use of electronic cigarettes are legal.[85]
  • In Portugal, with nicotine it is restricted, without nicotine it is not regulated.[85]
  • In Romania, the sale and use of electronic cigarettes are legal.[85]
  • In Switzerland, the sale of nicotine-free electronic cigarettes is legal. The use and importation of electronic cigarettes containing nicotine is legal, but they cannot be sold within the country.[95] As of December 2011, the tobacco tax does not apply to e-cigarettes and respective liquids containing nicotine.[96]
  • In the United Kingdom, the use, sale and advertising of electronic cigarettes are legal and electronic cigarettes are not covered by smoking bans.[97] In 2014 the government announced legislation would be brought forward to outlaw the purchase of electronic cigarettes by people under the age of 18.[97]
  • Wales could become the first part of the United Kingdom to ban electronic cigarettes in enclosed public spaces due to unsupported[98] fears their use could "re-normalise" smoking conventional cigarettes.[99]

United States

Federal regulation

The FDA classified electronic cigarettes as drug delivery devices and subject to regulation under the Food, Drug, and Cosmetic Act (FDCA) before importation and sale in the United States. The classification was challenged in court, and overruled in January 2010 by Federal District Court Judge Richard J. Leon, citing that "the devices should be regulated as tobacco products rather than drug or medical products."[100][101] As of April 2014, the FDA plans on making new regulations for electronic cigarettes.[4][102]

In March 2010, the U.S. Court of Appeals for the District of Columbia stayed the injunction pending an appeal, during which the FDA argued the right to regulate electronic cigarettes based on their previous ability to regulate nicotine replacement therapies such as nicotine gum or patches. Further, the agency argued that tobacco legislation enacted the previous year "expressly excludes from the definition of 'tobacco product' any article that is a drug, device or combination product under the FDCA, and provides that such articles shall be subject to regulation under the pre-existing FDCA provisions."[103] On 7 December 2010, the appeals court ruled against the FDA in a 3–0 unanimous decision, ruling the FDA can only regulate electronic cigarettes as tobacco products, and thus cannot block their import.[104] The judges ruled that such devices would only be subject to drug legislation if they are marketed for therapeutic use – E-cigarette manufacturers had successfully proven that their products were targeted at smokers and not at those seeking to quit. The District Columbia Circuit appeals court, on 24 January 2011, declined to review the decision en banc, blocking the products from FDA regulation as medical devices.[105]

State regulation

With an absence of federal regulations, many states and cities have adopted their own e-cigarette regulations, most commonly to prohibit sales to minors, including Maryland, Kentucky, Minnesota, New Jersey, New Hampshire, Tennessee, Utah, Wisconsin, and Colorado. Other states are considering similar legislation.[106]

  • California Governor Arnold Schwarzenegger vetoed a bill that would regulate the sale of electronic cigarettes within the state on grounds that "if adults want to purchase and consume these products with an understanding of the associated health risks, they should be able to do so."[107] Senate Bill 648(Authored by Senator Ellen Corbett), proposed a bill that would classify eCigarettes as tobacco products, thus banning their use wherever smoking was banned. In August 2013, SB648 was shelved for the session, just hours before its hearing in the State Assembly. It has not been determined if Sen Corbett will revise the bill and re-introduce it in 2014.[108]
    • A number of California cities have chosen to ban electronic cigarettes from public places, including Los Angeles,[109] Long Beach,[110] and Carlsbad.[111]
  • New Jersey voted in 2009 to treat the electronic cigarette in the same category as tobacco products by including them under the New Jersey Smoke-Free Air Act, which prohibits smoking in indoor work and public places. Assemblywoman Connie Wagner sponsored the legislation, claiming "that young people who use these things will get hooked on the nicotine and eventually move onto the real thing".[112]
  • In New Hampshire, the sale of electronic cigarettes to minors is illegal as of July 2010.[113]
  • Arizona is planning to ban the sale of electronic cigarettes to minors.[114]
  • In Maryland, sales to minors are banned.[115]
  • New York State banned the use of e-cigarettes within 100 feet of a public or private school entrance in September 2012, and banned e-cigarette sales to minors starting on 1 January 2013.[116]
    • On 30 December 2013, New York City mayor Michael Bloomberg signed a bill regulating e-cig usage in the same way as that of normal cigarettes. The bill was signed on his second to last day in office after the council approved regulation. One of the arguments from proponents of the bill was a need for contrast between on one hand claiming usage "safe" and on the other "safer than cigarettes, but still potentially dangerous."[117][118][119]
  • In Pennsylvania, SB 1055 was introduced by Sen. Tim Solobay in 2013 and would ban sales to minors.[120] That same year physician members of the Pennsylvania Medical Society called upon the state legislature to pass electronic cigarette laws that have safeguards equivalent to existing tobacco laws.[121]
  • New Kansas law that goes into effect July 1, 2012 bans possession of e-cigarettes by anyone under 18.[122]

Other countries

  • In Australia, the Federal Department of Health and Ageing classifies every form of nicotine, except for replacement therapies and cigarettes, as a form of poison.[123][124] The Therapeutic Goods Administration has said that there were no laws preventing the importation of e-cigarettes bought over the internet for personal use, unless prohibited by state and territory legislation.[125] State laws in Australia's various states are a little bit conflicting. According to the Poisons Standard of 2010, inhaled nicotine is Pharmacy Only, or a Schedule 2 medication when used to help quit smoking.[126][127] In April 2014 Western Australia made it illegal to sell or supply electronic cigarettes regardless of their appearance.[5] Previously they were banned if they looked like cigarettes. The court ruled that the action they provided in and of itself looks like cigarettes.
  • In Argentina, sales, importation and manufacturing have been banned by the local regulatory authority as well as its use has been discouraged by the National Clinical Practice Guideline for Tobacco Cessation from lack of enough evidence.[128]
  • In Brazil, the sale, importation and advertising of any kind of electronic cigarette is forbidden. The Brazilian health and sanitation federal agency, Anvisa, found the current health safety assessments about e-cigarettes to not be yet satisfactory for commercial approval eligibility.[129]
  • In Canada, as of March 2014, while the importation, sale, and advertising of electronic cigarettes containing nicotine is permitted, manufacturers and retailers may not make any claims about the products' efficacy for any health purpose.[citation needed]
  • In China, the sale and use of electronic cigarettes is legal.[citation needed]
  • In Egypt, the Egyptian Ministry of Health technical committee has rejected applications for marketing authorization of electronic cigarettes on the grounds that they contain harmful chemicals, and lack safety and toxicity data.[citation needed]
  • In Hong Kong the sale and possession of nicotine-based electronic cigarettes, classified as a Type I Poison, is governed under the Pharmacy and Poisons Ordinance. Sale or possession is not authorized and both are considered punishable with a fine of up to HK$100,000 and/or a prison term of 2 years. However, the law does not cover any non-nicotine inhalers.[130]
  • In India, the use of electronic cigarettes is legal. Under the Indian Health Law of 2006, tobacco smoking has been banned in public. Since e-cigarettes avoid the use of tobacco, they do not fall under this law.[131]
  • In Israel in 2013, the Ministry of Health planned to extend existing laws on smoking in public places to e-cigarettes, a year after warning against the product's usage.[132]
  • In Japan, no laws pertaining specifically to the use of electronic cigarettes exists. However, the sale of products containing nicotine in Japan is regulated and no express permission to sell e-liquids containing nicotine has been given. Because of this, the sale of vaporizers is legal, but the sale of e-liquid is not. Individuals may however import e-liquid from overseas for personal use.
  • In Lebanon, the council of ministers has banned the sale and use of electronic cigarettes, starting 21 September 2011.[citation needed]
  • In Malaysia, the sale of e-cigarettes is an offence under the Poisons Act 1952 and the Control of Drugs and Cosmetics Regulations 1984. Those found guilty of selling and distributing the product (as well as liquid nicotine for use in electronic cigarettes) will be fined no more than RM3,000, be jailed for no more than two years, or both.[133] The Malaysian Health Minister stated that e-cigarettes containing liquid nicotine are more harmful than normal cigarettes and warned Malaysians to avoid them.[134]
  • In Mexico, the Federal Commission for the Protection Against Sanitary Risks, announced that according to Mexican Law, the selling and promotion of non-tobacco objects that include elements generally associated with tobacco products are forbidden.[135]
  • In Nepal, under current cigarette laws, the use and sale of e-cigarettes is permitted. [citation needed]
  • In Pakistan, the import and sale of electronic cigarettes is legal, but Pakistan Medical and Dental council find that the current health safety assessments of e-cigarettes to not yet be satisfactory. [citation needed]
  • In Panama, the importation, distribution and sale of electronic cigarettes have been prohibited since June 2009. The Ministry of Health cites the FDA findings as their reasoning for the ban.[136]
  • In Singapore, electronic cigarettes (e-cigarettes) are currently prohibited under Section 16 (1) of the Tobacco (Control of Advertisements and Sale) Act, which is enforced by the Health Sciences Authority (HSA). This legislation prohibits the importation, distribution, sale or offer for sale of any confectionery or other food product or any toy or other article that is designed to resemble a tobacco product or the packaging of which is designed to resemble the packaging commonly associated with tobacco products. HSA takes a serious view on any person who contravenes the law. Those guilty of the offence are liable to a fine of up to $5, 000 upon conviction.[137] According to Health Minister Khaw Boon Wan, electronic cigarettes are the industry's attempt to attract new users and were marketed to appeal to younger customers, including women.[138]
  • In South Korea, the sale and use of electronic cigarettes is legal, but is heavily taxed. Electric cigarette possession among teenagers remains an issue.[139]
  • In Turkey, the sale of electronic cigarettes and e-liquids are illegal.
  • In United Arab Emirates, the sale and use of electronic cigarettes is illegal.[140]

There are other technologies currently under development that seek to deliver nicotine for oral inhalation in an effort to mimic both the ritualistic and behavioural aspects of traditional cigarettes.

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