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: email@example.com.
Received Date: 12 April, 2018; Accepted Date: 23 April, 2018; Published Date: 01 May, 2018
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.
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 . 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 . 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 . 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 . 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 . 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  and malignant disease  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 .
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 . 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 . Propylene glycol has the potential to cause throat eye and airway irritation  and asthma in children subsequent to long term exposure . 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 .
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 . 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 . 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  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 . A variety of e-cigarette solution flavors include peppermint, chocolate, piña colada candy, coffee, bubble gum,  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 . 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.
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 .
Figure 2: Components of an electronic cigarette.
5. The WHO tobacco products survey on smokeless, electronic nicotine delivery systems, reduced ignition propensity cigarettes, and novel tobacco products was sent to all WHO Member States. A total of 90 WHO Member States, including 86 Parties to the WHO FCTC, had responded to the survey as at 9 April 2014. These countries are: Australia, Austria, Bahrain, Bangladesh, Barbados, Belarus, Belgium, Belize, Bhutan, Bolivia (Plurinational State of), Botswana, Brazil, Brunei Darussalam, Cambodia, Canada, Chile, China, Colombia, Congo, Costa Rica, Croatia, Czech Republic, Djibouti, Dominica, Ecuador, Egypt, Estonia, Fiji, Finland, France, Gabon, Georgia, Ghana, Guatemala, Honduras, Hungary, Iceland, India, Indonesia, Iran (Islamic Republic of), Iraq, Jamaica, Japan, Jordan, Kenya, Kuwait, Lao People’s Democratic Republic, Latvia, Lebanon, Lithuania, Malaysia, Maldives, Mali, Mauritania, Mongolia, Morocco, Myanmar, Netherlands, New Zealand, Nicaragua, Norway, Oman, Pakistan, Palau, Panama, Paraguay, Peru, Philippines, Poland, Qatar, Republic of Korea, Russian Federation, Slovakia, South Sudan, Spain, Sudan, Suriname, Sweden, Syrian Arab Republic, Thailand, Tonga, Tunisia, Turkey, Tuvalu, United Arab Emirates, United States of America, Uruguay, Uzbekistan, Vietnam, and Zambia.
13. Wieslanmder G, Norback D, Lingren T (2001) Experimental exposure to propylene glycol mist in aviation emergency training: Acute occular and respiratory effects. Occupational Environ Med 58: 649-655.
22. The scientific basis of tobacco product regulation: a WHO Study Group on Tobacco Product Regulation report. Candy-flavoured tobacco products: research needs and regulatory recommendations. Geneva; World Health Organization: 2007.
23. Flouris AD, Chorti M, Poulianiti K, Jamourtas A, Kostikas K, et al. (2013) Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhalation Toxicol 25: 91-101.
27. Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, et al. (2014) Nicotine absorption from electronic cigarette use: Comparison between first and new generation devices. Scientific Reports 4: 4133.
30. U.S. Dept of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, Ga.: U.S. Department of Health and Human Services, Centers for Disease Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 2015.
Citation: Shah S (2018) Use of Electronic Cigarettes Among Children and Adolescents. Clin Pharmacol Toxicol: ACPT-110. DOI: 10.29011/2577-0225. 000010