Public Health Consequences of E-Cigarettes

613 Pages·2017·6.47 MB·English

THE NATIONAL ACADEMIES PRESS
This PDF is available at http://nap.edu/24952 SHARE
Ū ſ Ŷ Þ
Public Health Consequences of E-Cigarettes
DETAILS
680 pages | 6 x 9 | PAPERBACK
ISBN 978-0-309-46834-3 | DOI 10.17226/24952
CONTRIBUTORS
GET THIS BOOK Kathleen Stratton, Leslie Y. Kwan, and David L. Eaton, Editors; Committee on the
Review of the Health Effects of Electronic Nicotine Delivery Systems; Board on
Population Health and Public Health Practice; Health and Medicine Division;
FIND RELATED TITLES National Academies of Sciences, Engineering, and Medicine
Visit the National Academies Press at NAP.edu and login or register to get:
– Access to free PDF downloads of thousands of scientific reports

– 10% off the price of print titles

– Email or social media notifications of new titles related to your interests

– Special offers and discounts
Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press.
(Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences.
Copyright © National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
Public Health Consequences of
E-Cigarettes
Committee on the Review of the Health Effects of Electronic Nicotine Delivery
Systems
Kathleen Stratton, Leslie Y. Kwan, and David L. Eaton, Editors
Board on Population Health and Public Health Practice
Health and Medicine Division
A Consensus Study Report of
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract No. HHSF223201610054C between the National
Academy of Sciences and the U.S. Department of Health and Human Services: Food and Drug
Administration. Any opinions, findings, conclusions, or recommendations expressed in this
publication do not necessarily reflect the views of any organization or agency that provided
support for the project.
International Standard Book Number-13: 978-0-309-XXXXX-X
International Standard Book Number-10: 0-309-XXXXX-X
Digital Object Identifier: https://doi.org/10.17226/24952
Library of Congress Control Number:
Additional copies of this publication are available for sale from the National Academies Press,
500 Fifth Street, NW, Keck 360, Washington, DC 20001; [phone] or [phone];
http://www.nap.edu.
Copyright 2018 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Public
health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi:
https://doi.org/10.17226/24952.
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by
President Lincoln, as a private, nongovernmental institution to advise the nation on issues
related to science and technology. Members are elected by their peers for outstanding
contributions to research. Dr. Marcia McNutt is president.
The National Academy of Engineering was established in 1964 under the charter of the
National Academy of Sciences to bring the practices of engineering to advising the nation.
Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D.
Mote, Jr., is president.
The National Academy of Medicine (formerly the Institute of Medicine) was established in
1970 under the charter of the National Academy of Sciences to advise the nation on medical
and health issues. Members are elected by their peers for distinguished contributions to
medicine and health. Dr. Victor J. Dzau is president.
The three Academies work together as the National Academies of Sciences, Engineering,
and Medicine to provide independent, objective analysis and advice to the nation and
conduct other activities to solve complex problems and inform public policy decisions. The
National Academies also encourage education and research, recognize outstanding
contributions to knowledge, and increase public understanding in matters of science,
engineering, and medicine.
Learn more about the National Academies of Sciences, Engineering, and Medicine at
www.nationalacademies.org.
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
Consensus Study Reports published by the National Academies of Sciences, Engineering, and
Medicine document the evidence-based consensus on the study’s statement of task by an
authoring committee of experts. Reports typically include findings, conclusions, and
recommendations based on information gathered by the committee and the committee’s
deliberations. Each report has been subjected to a rigorous and independent peer-review
process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and
Medicine chronicle the presentations and discussions at a workshop, symposium, or
other event convened by the National Academies. The statements and opinions contained in
proceedings are those of the participants and are not endorsed by other participants, the
planning committee, or the National Academies.
For information about other products and activities of the National Academies, please
visit www.nationalacademies.org/about/whatwedo.
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
COMMITTEE ON THE REVIEW OF THE HEALTH EFFECTS OF ELECTRONIC
NICOTINE DELIVERY SYSTEMS
DAVID L. EATON (Chair), Dean and Vice Provost, Graduate School, University of
Washington
ANTHONY J. ALBERG, Professor and Chair, Department of Epidemiology and Biostatistics,
Arnold School of Public Health, University of South Carolina
MACIEJ GONIEWICZ, Associate Professor of Oncology, Roswell Park Comprehensive Cancer
Center
ADAM LEVENTHAL, Director, USC Health, Emotion, & Addiction Laboratory, Professor of
Preventive Medicine and Psychology, USC Norris Comprehensive Cancer Center, Keck
School of Medicine, University of Southern California
JOSÉ E. MANAUTOU, Professor of Pharmacology & Toxicology, Interim Head, Department of
Pharmaceutical Sciences, University of Connecticut
SHARON MCGRATH-MORROW, Professor, Department of Pediatrics, Eudowood Division of
Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine
DAVID MENDEZ, Associate Professor, Health Management and Policy, University of Michigan
RICHARD MIECH, Research Professor, Department of Youth and Social Issues, University of
Michigan
ANA NAVAS-ACIEN, Professor, Department of Environmental Health Sciences, Mailman
School of Public Health, Columbia University
KENT E. PINKERTON, Professor and Director, Center for Health and the Environment,
Department of Anatomy, Physiology, and Cell Biology, University of California, Davis
NANCY A. RIGOTTI, Professor of Medicine, Harvard Medical School, Director, Tobacco
Research and Treatment Center, Associate Chief, Division of General Internal Medicine,
Massachusetts General Hospital
DAVID A. SAVITZ, Vice President for Research, Professor of Epidemiology, Professor of
Obstetrics and Gynecology, Brown University
GIDEON ST.HELEN, Assistant Professor, Zuckerberg San Francisco General Hospital
Study Staff
KATHLEEN STRATTON, Study Director
LESLIE Y. KWAN, Associate Program Officer
AIMEE MEAD, Research Associate (from July 2017)
ALEXIS WOJTOWICZ, Senior Program Assistant
JORGE MENDOZA-TORRES, Senior Research Librarian
REBECCA MORGAN, Senior Research Librarian
DORIS ROMERO, Financial Associate (until March 2017)
MISRAK DABI, Financial Associate (from April 2017)
HOPE HARE, Administrative Assistant
ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health
Practice
Christine Mirzayan Science and Technology Policy Graduate Fellow
ANDREW MERLUZZI, Ph.D. Candidate at the University of Wisconsin–Madison (until April
2017)
v
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
REVIEWERS
This Consensus Study Report was reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise. The purpose of this independent review is to
provide candid and critical comments that will assist the National Academies of Sciences,
Engineering, and Medicine in making each published report as sound as possible and to ensure
that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to
the study charge. The review comments and draft manuscript remain confidential to protect the
integrity of the deliberative process.
We thank the following individuals for their review of this report:
R. GRAHAM BARR, Columbia University Medical Center
NEAL L. BENOWITZ, University of California, San Francisco
JOHN BRITTON, University of Nottingham
CRISTINE D. DELNEVO, Rutgers, The State University of New Jersey
JOANNA S. FOWLER, Brookhaven National Laboratory and National Institutes of Health
MARIANNA D. GAउA, British American Tobacco Research and Development Centre
STEPHEN S. HECHT, University of Minnesota
HARLAN R. JUSTER, New York State Department of Health
PAULA M. LANTZ, University of Michigan
RAFAEL MEZA, University of Michigan
MEIR STAMPFER, Harvard Medical School and Harvard T.H. Chan School of Public
Health
THOMAS A. WILLS, University of Hawaii Cancer Center
JUDITH T. ZELIKOFF, New York University School of Medicine
SHU-HONG ZHU, University of California, San Diego
Although the reviewers listed above provided many constructive comments and suggestions,
they were not asked to endorse the conclusions or recommendations of this report nor did they
see the final draft before its release. The review of this report was overseen by ERIC B.
LARSON, Kaiser Permanente Washington Health Research Institute, and HUDA AKIL,
University of Michigan. They were responsible for making certain that an independent
examination of this report was carried out in accordance with the standards of the National
Academies and that all review comments were carefully considered. Responsibility for the final
content rests entirely with the authoring committee and the National Academies.
vii
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
Copyright National Academy of Sciences. All rights reserved.
Public Health Consequences of E-Cigarettes
PREFACE
On May 10, 2016, the Food and Drug Administration (FDA) issued a rule to extend
regulatory authority to all tobacco products, including e-cigarettes that meet the statutory
definition of a tobacco product. This so-called “Deeming Regulation” allows FDA to regulate
the manufacturing, distribution, and marketing of tobacco products such as e-cigarettes and
includes automatic provisions such as youth access restrictions on sales. Although various forms
of battery-powered “Electronic Nicotine Delivery Systems” (ENDS devices) have existed for
more than a decade, their popularity, especially among youth, has increased in the past 5 years,
although most recent data show a slight decline. In contrast to combustible tobacco cigarettes, e-
cigarettes do not “burn,” and do not contain most of the estimated 7,000 chemical constituents
present in tobacco smoke. Thus, it is generally believed that e-cigarettes are “safer” than
combustible tobacco cigarettes, yet exposures to nicotine and a variety of other potentially
harmful constituents do occur. Harm might also occur if youth who begin their “tobacco” use
with e-cigarettes then transition to combustible tobacco cigarettes or if adult cigarette smokers
use e-cigarettes to supplement their smoking, rather than quitting combustible tobacco cigarettes
completely.
In order to inform the public about the consequences of e-cigarettes and in support of
future FDA and congressional action, a thorough and objective analysis of the state of scientific
evidence relating to e-cigarettes and public health is needed. To that end, the ENDS Committee
was established in December 2016 under the National Academies of Sciences, Engineering, and
Medicine, with an ambitious timeline to complete a review of the science that can inform the
understanding of public health risks and benefits of e-cigarettes. What are the short- and long-
term health risks of regular use of e-cigarettes? What variables of the numerous types of devices
and use patterns are important determinants of risk? Are e-cigarettes an effective means to quit
smoking combustible tobacco cigarettes? Are e-cigarettes an “initiation pathway” of youth to
smoking combustible tobacco cigarettes? These are just some of the important questions
addressed by the committee in this report. Where feasible, the committee applied the most
important attributes of systematic review methodology to the scientific literature to establish the
strength of evidence surrounding the health risks (e.g., direct harmful effects, initiation of
smoking) and benefits (e.g., smoking cessation) associated with e-cigarette use. Although the use
of these products is relatively new, the committee identified more than 800 peer-reviewed
scientific studies in this report. Based on this review, the committee has provided a summary of
the current state of knowledge about the health risks and benefits of e-cigarette use, and has
provided a series of research recommendations.
I am deeply gratified by the remarkable hard work and insights provided by my fellow
committee members and indebted to the tireless and thoughtful work of the National Academies
staff that so ably kept us on task throughout the duration of this task.
David L. Eaton, Chair
Committee on the Health Effects of Electronic Nicotine Delivery Systems
ix
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright National Academy of Sciences. All rights reserved.