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Vaping and e-cigarettes

: Nancy A Rigotti, MD, Krishna P Reddy, MD
: Mark D Aronson, MD, Umur Hatipoglu, MD, MBA
: Sara Swenson, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2023.

This topic last updated: Dec 07, 2022.

INTRODUCTION

Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid usually
containing nicotine, producing an aerosol that the user inhales ( figure 1) [1]. E-cigarettes
entered the market in 2003 in China and entered the United States and European markets in
2006 [2]. In many areas, e-cigarettes entered the market as consumer products without
government regulation. Initially produced by small companies, tobacco companies have
bought some of these companies and are developing these products [3]. They are available
both online and in traditional retail outlets.

There is uncertainty about the long-term health effects of e-cigarettes and whether they will
help individual tobacco users to stop smoking [4-7]. There are also public health concerns,
including concerns about the effect of e-cigarettes on smoking prevalence and their potential
use by children as a gateway to nicotine dependence and subsequent combustible tobacco
product use [8].

This topic will provide an overview of e-cigarettes, including information about devices, use,
components, adverse health effects, use in smoking cessation, impact on public health, as
well as suggestions for patient counseling. An overview of smoking cessation and
pharmacotherapies and behavioral therapies for smoking cessation are discussed in detail in
the following topic reviews:

(See "Overview of smoking cessation management in adults".)

(See "Pharmacotherapy for smoking cessation in adults".)
(See "Behavioral approaches to smoking cessation".)
 (See "Prevention of smoking and vaping initiation in children and adolescents", section
on 'Vaping nicotine'.)
(See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment
options".)
(See "Cigarette and tobacco products in pregnancy: Impact on pregnancy and the
neonate".)

ELECTRONIC NICOTINE DELIVERY SYSTEMS

E-cigarette devices — E-cigarettes are a type of electronic nicotine delivery system (ENDS)

consisting of a cartridge containing a liquid, an atomizer (vaporization chamber with a
heating element), and a battery ( figure 1) [9].

The user activates the atomizer either by inhaling or by pressing a button, depending on the
device characteristics. The atomizer then heats and aerosolizes the liquid in the cartridge,
creating an aerosol that emulates but is not tobacco smoke. This process simulates the
experience of smoking a conventional cigarette, but no combustion occurs. The term "vaping"
is used to distinguish the process from smoking a conventional cigarette. The term “dripping”
is used to describe a technique in which a couple of drops of the liquid in the e-cigarette
cartridge are dripped directly onto the atomizer’s heating element to create a cloud of aerosol
that can be inhaled [10].

E-cigarettes originally were designed to resemble conventional cigarettes, but e-cigarette

technology is rapidly evolving. Newer versions resemble cigarettes less and feature
rechargeable batteries as well as heating elements and refillable cartridges that can deliver
higher concentrations of nicotine ( figure 2) [1].

First-generation products – First-generation e-cigarettes mimic the shape and size of

conventional cigarettes and may be referred to as "cigalikes." They are neither
rechargeable nor refillable and are discarded after they stop producing aerosol.

Second-generation products – Second-generation e-cigarettes are larger than

conventional cigarettes and are either pen-style (medium size) or tank-style (large size).
Both feature rechargeable batteries that may have a switch or electronic circuits that
allow users to regulate the frequency and length of puffs or the power delivery to the
atomizer. The cartridges in second-generation e-cigarettes are refillable and allow the
user to adjust the contents of the e-cigarette liquid.

Third-generation products – Third-generation e-cigarettes are similar to second-

generation devices but allow for more custom modifications [1]. They are known as
"personalized vaporizers." There are a range of options for cartridges and atomizers;
 some devices allow the user to adjust the resistance of the atomizer, which produces
higher heating temperatures. Users can also pair different atomizers with high-capacity
batteries to increase aerosol production and battery life.

Fourth-generation products – “Pod-mod devices” are a type of e-cigarette that has been
increasing in popularity among adolescents [11]. These rechargeable devices have
replaceable cartridges that contain nicotine and flavorings. A popular brand is JUUL, a
device that resembles a USB flash drive. JUUL’s small size and discreet appearance make
it easy for the device use to go unnoticed in school settings. JUUL devices can deliver
higher concentrations of nicotine without throat irritation because they contain nicotine
in a form that is less irritating to the throat.

Novel devices – Similar to first-generation products, these small, often brightly colored
devices are non-rechargeable and disposable, and they are available in many flavors (eg,
fruit, candy, mint) [12-14].

E-cigarette liquid components — Unlike conventional cigarettes, which burn tobacco and

generate smoke, e-cigarettes have a cartridge containing a liquid (sometimes referred to as
"vape juice," "e-juice," or "e-liquid"). The liquid is heated to produce an aerosol the user
inhales [1]. Nicotine e-cigarettes contain nicotine and other constituents, some with
carcinogenic potential [1,15-18]:

Nicotine – The nicotine content of e-cigarettes and liquids varies and usually ranges
from none (nicotine-free) up to 36 mg/mL, though it can be higher [1,19]. Common
nicotine concentrations of e-cigarette liquids are 6 mg/mL, 12 mg/mL, 18 mg/mL, or 24
mg/mL. Some e-cigarette liquids contain nicotine salts, in which nicotine is combined
with an acid [20]. Use of nicotine salts may have a different sensation in a user’s throat
[20].

Propylene glycol/glycerol – Propylene glycol or glycerol are humectants that are the
main components of most e-cigarette liquids; some products may use ethylene glycol
[21].

Flavorings – E-cigarettes may have added characterizing flavors. More than 7000 flavors
are available, including candy, fruit, soda, and alcohol flavors [22]. Flavorings may
increase the attractiveness of e-cigarettes to youths, especially those who do not already
smoke [23].

Metals such as tin, lead, nickel, chromium, manganese, and arsenic have been found in some
e-cigarette liquids and aerosol [24,25]. Other compounds detected include tobacco-specific
nitrosamines, carbonyl compounds, metals, volatile organic compounds, and phenolic
compounds [1,18,26,27]. Vaping devices can be used to aerosolize tetrahydrocannabinol
(THC) or cannabinoid (CBD) oils.

Heat-not-burn tobacco products — Another type of heating device is used in heat-not-burn

(HNB) tobacco products. The device heats tobacco to a much lower temperature than that of a
conventional tobacco cigarette. In July 2020, the US Food and Drug Administration (FDA)
approved the manufacturer’s request to market these devices with the claim that they reduce
exposure to tobacco toxins [28]. HNB products are described separately. (See "Patterns of
tobacco use", section on 'Heat-not-burn tobacco products'.)

PREVALENCE AND PATTERNS OF USE

Prevalence

Adults – The National Health Interview Survey (NHIS), which provides nationally
representative estimates of e-cigarette use among adults in the United States, showed
an overall increase in the prevalence of current e-cigarette use among adults between
2014 to 2019 (from 3.7 to 4.9 percent), with a decline in 2020 (to 3.7 percent) [29-32].
Between 2018 and 2020, however, the prevalence of e-cigarette use among young adults
(ages 18 to 24 years) increased from 7.6 to 9.4 percent.

Youth – Between 2013 and 2019, national surveys of middle and high school students in
the United States revealed an upward trend in e-cigarette use in the past 30 days (the
measure used to define current use among adolescents), with the greatest increase
being in e-cigarette use ( figure 3 and figure 4) [23,33-35].

However, a large decline in e-cigarette use among United States adolescents was
reported in the 2020 National Youth Tobacco Survey (NYTS) [14]. In 2020, 19.6 percent of
high school students reported current use of e-cigarettes, compared with 28 percent in
2019; among middle school students, 4.7 percent reported current use compared with
11 percent in 2019 [35].

The 2021 NYTS reported a further decline in overall youth tobacco and e-cigarette use
that was coincident with the coronavirus disease 2019 (COVID-19) pandemic, when many
schools shifted from in-person to remote learning [36]. Among high school students, e-
cigarette use declined to 11.3 percent, and among middle school students, use declined
to 2.8 percent. Some of the difference may be attributable to a change in survey
methodology, because the 2021 survey was administered to students both remotely and
in-school settings. However, the large size of the decline between years likely represents
a decline of some magnitude in the prevalence of youth’s tobacco and e-cigarette use.
Some of the decline in e-cigarette use might be attributable to social distancing among
 adolescents that occurred because schools were closed for in-person learning for much
of much of 2021.

The 2022 NYTS reported a partial rebound in e-cigarette use among United States
adolescents with 14.1 percent of high school students and 3.3 percent of middle school
students reporting current use (versus 11.3 and 2.8 percent in 2021) [37]. These findings
may represent true changes in use patterns in the context of more students returning to
in-person school, but they may also be influenced by the change to online survey
methodology for all participants in 2022.

The prevalence of daily e-cigarette use by adolescents is much lower than the measure
of current (past 30-day) use. In the 2022 NYTS, daily e-cigarette use was reported by only
4.2 percent of high school students and 1.0 percent of middle school students.

Patterns of use — E-cigarette use (ever or current use) is more common among younger age
groups, males, and non-Hispanic White adults [32,38-40].

Youth e-cigarette users are generally nondaily users of the product [41-43]. As an example,
the 2020 NYTS found that, among current e-cigarette users, 22.5 percent of high school
students and 9.4 percent of middle school students were daily users [14]. In another study,
adults who recently quit smoking were more likely to be regular e-cigarette users than others
who formerly smoked [44].

Most adult current users of e-cigarettes currently or previously used conventional cigarettes
[38,40]. The 2018 NHIS reported that 6.5 percent of adults who had never smoked cigarettes
had ever used an e-cigarette and 1.1 percent of those who had never smoked were current e-
cigarette users [38]. In the United Kingdom in 2015, an estimated 1.7 percent of those who
had never smoked were current e-cigarette users [45].

Data from the NHIS in the United States suggest an increase in e-cigarette use among adults
who previously smoked and some who have never smoked. From 2017 to 2018, the
prevalence of current e-cigarette use among those who previously smoked increased from 4.2
to 5.5 percent [29]. Among young adults, current e-cigarette use increased from 2014 to 2018
among those who previously smoked (from 10.4 to 36.5 percent) and among those who never
smoked (from 1.5 to 4.6 percent) [30]. The prevalence of e-cigarette use among those who
currently smoke remained stable.

In surveys and a cross-sectional secondary data analysis of a randomized trial, a majority of e-

cigarette users perceive these products to be a tool to quit conventional cigarettes or to
reduce their risk of tobacco-related disease [40,46,47]. For example, in a survey of 2501
United States adults who smoke, there was a greater interest in using e-cigarettes for the
purpose of smoking cessation or reduction than for novelty or to cope with smoking
restrictions [48].

ADVERSE HEALTH EFFECTS

Potential adverse effects of e-cigarettes are related to exposure to nicotine as well as to other
aerosol components produced by the devices and risks of the actual device.

Nicotine exposure — Nicotine exposure from e-cigarette use, as with cigarette smoking,

increases heart rate and produces measurable levels of blood cotinine, a nicotine metabolite
[49]. (See "Cardiovascular effects of nicotine", section on 'Smoking and cardiovascular risk'.)

The amount of nicotine delivered and the level of nicotine in the blood varies depending on
nicotine concentration in the e-cigarette liquid, other components in the e-cigarette liquid,
user experience, puffing intensity, device characteristics, and vaping technique [50].
Experienced e-cigarette users tend to take longer puffs and use the device more intensively
compared with novice users [51]. As a consequence, they have higher blood nicotine levels
that more closely resemble the levels achieved by smoking conventional cigarettes [1,49,52-
54]. In less-experienced users, however, the nicotine delivered by e-cigarettes is consistently
lower than nicotine delivered by conventional cigarettes [55,56].

Data on the health consequences of chronic nicotine exposure alone in the absence of
cigarette smoking are available from studies of chronic users of nicotine replacement
products. These data do not suggest that chronic nicotine exposure increases long-term
cardiopulmonary or cancer risk. (See "Cardiovascular effects of nicotine", section on 'Safety of
nicotine replacement therapy'.)

Aerosol (also known as vapor) exposure — Commercially manufactured e-cigarettes do not

expose the user to many of the constituents of cigarette smoke (eg, tars, oxidant gases, and
carbon monoxide) that are responsible for many of the tobacco-attributable diseases [57].
However, most manufactured e-cigarettes do contain a number of potentially toxic chemical
substances [1]. Furthermore, people may refill empty e-cigarette cartridges with various
substances and carriers that may increase risk of harm when heated for inhalation.

In 2019, the Centers for Disease Control and Prevention (CDC) reported over two thousand
suspected cases of severe lung illnesses (e-cigarette, or vaping, product use associated lung
injury [EVALI]) linked to the use of e-cigarette devices to aerosolize substances for inhalation
[58-63]. In the majority of cases, tetrahydrocannabinol (THC) had been inhaled within three
months of symptom onset; many patients had also inhaled nicotine, and some patients had
inhaled only nicotine [61]. Refilled e-cigarette cartridges obtained via informal or illicit sources
and contaminated with vitamin E acetate appear to be most strongly associated with EVALI
cases, and vitamin E acetate has been detected in bronchoalveolar lavage fluid samples
obtained from affected patients [59,60,64]. EVALI is discussed in greater detail elsewhere. (See
"E-cigarette or vaping product use-associated lung injury (EVALI)".)

E-cigarette use has also been associated with the development of acute eosinophilic
pneumonia. (See "Idiopathic acute eosinophilic pneumonia", section on 'Etiology'.)

Prior to the emergence of EVALI, most experts believed that inhaling e-cigarette aerosol was
less likely to be harmful (acutely or chronically) than inhaling cigarette smoke [1,2,65]. The
consequences of chronic e-cigarette aerosol inhalation are largely unknown, and levels of
toxic and carcinogenic compounds may vary depending on the e-cigarette liquid components
and device used [66]. Little is known about the overall safety or the carcinogenic effects of
propylene glycol or glycerol when heated and aerosolized. At high temperatures, propylene
glycol decomposes and may form propylene oxide, a probable human carcinogen [67].
Glycerol produces the toxin acrolein, though the levels produced are lower than conventional
cigarettes [15]. Both propylene glycol and glycerol decompose to form the carcinogens
formaldehyde and acetaldehyde, with levels depending on the voltage of the battery used in
the e-cigarette [66,68].

Other carcinogenic compounds have been found in e-cigarettes, but in trace amounts that are
much lower than levels found in conventional cigarettes. These include tobacco-specific
nitrosamines (TSNAs), carbonyl compounds, metals, volatile organic compounds (VOCs), and
phenolic compounds [1,18,26,27]. A small observational study found that users of e-cigarettes
for at least six months (who did not smoke conventional cigarettes) had substantially lower
urinary and salivary concentrations of TSNAs and VOCs than did those who smoked
conventional cigarettes [53]. It is not known whether the particles in e-cigarette aerosol have
any toxicity. (See "Secondhand smoke exposure: Effects in adults" and "Secondhand smoke
exposure: Effects in children", section on 'Is exposure to e-cigarette vapor harmful?'.)

The long-term cardiovascular risks of e-cigarette use are unknown but are thought to be
substantially lower than the risks of smoking [69]. Aerosol constituents that may influence
this risk include nicotine, oxidizing chemicals, particulate matter, and acrolein [70]. A small
observational study found that e-cigarette use for at least one year was associated with
factors that have been correlated with increased cardiovascular risk: increased oxidative
stress and a shift toward sympathetic predominance in cardiac autonomic balance [71]. By
contrast, another small study found that, compared with a sham control or non-nicotine e-
cigarette, acute exposure to an e-cigarette containing nicotine was not associated with
increased oxidative stress but was associated with increased cardiac sympathetic nerve
activity [72]. A randomized control trial found that those who switched from conventional to
e-cigarettes had improvement in endothelial function and vascular stiffness within one month
[73].
The use of nicotine containing e-cigarettes may cause a mild, short-term increase in blood
pressure [72,74], although the long-term effects on blood pressure are unclear. (See "Smoking
and hypertension", section on 'E-cigarettes and blood pressure'.)

Although limited evidence on the effects of e-cigarette aerosol suggests that changes in
airway respiratory function are much smaller than those associated with conventional
cigarettes, there may be an association with cough and asthma symptoms, particularly
among adolescents [1,6]. In one survey of over 45,000 students (mean age 14.6 years) in
Hong Kong, e-cigarette use was associated with respiratory symptoms (cough or phlegm),
regardless of cigarette smoking status [75]. Similarly, in a survey of 11th- and 12th-grade
students in California, there was an association between self-reported chronic bronchitic
symptoms (chronic cough, phlegm, or bronchitis within the past year) and current or past e-
cigarette use that remained after adjustment for cigarette smoking or secondhand smoke
exposure; the risk increased with frequency of current e-cigarette use [76]. Among adults,
there is some evidence of an association between e-cigarette use and respiratory symptoms,
although the risk appears to be lower than that with cigarette smoking [77,78].

The effect of inhaling flavorings on respiratory function is also uncertain [79]. Some studies
have found a link between cytotoxicity and certain flavorings used in e-cigarette liquids,
especially sweet and cinnamon flavors [80-84]. Specifically, diacetyl, a chemical associated
with respiratory diseases, has been found in sweet-flavored e-cigarettes [85]. Cherry-flavored
e-cigarettes have been found to contain benzaldehyde, a compound that has been associated
with respiratory irritation [86].

No observational data examining the long-term risk of cancer from e-cigarettes exist;
however, the risk of cancer is likely to be much lower in adults who use e-cigarettes than in
those who smoke conventional cigarettes [1,69,87].

Risks of devices — E-cigarette devices have been reported to cause burns, explosive injuries,
and chemical injuries [69,88-91].

Several reviews have identified emergency department visits for burns from electronic
nicotine delivery systems (ENDS) due to device malfunction either while stored (eg, in a
pocket) or during use, resulting in burns to the thigh, groin, face, and/or hand [91,92].

In addition, exposure to e-cigarette liquid via oral or parenteral ingestion, or through skin
contact, can also cause harm, particularly to young children. Such exposure may commonly
cause nausea, vomiting, lethargy, and tachycardia and may even result in seizures, anoxic
brain injury, lactic acidosis, and death. (See "Nicotine poisoning (e-cigarettes, tobacco
products, plants, and pesticides)".)
CONCERNS RELATED TO YOUTH AND NONSMOKERS

For adolescents and others who are not established cigarette smokers, the primary focus is
on the potential risks of e-cigarette use. Non-smokers are not using e-cigarettes to help them
stop using conventional cigarettes, so there is no mitigating harm-reduction. Concerns about
the risks of e-cigarettes are accentuated by the rapidly increasing prevalence of e-cigarette
use among youth in the United States ( figure 3 and figure 4), with many adolescents
reporting very frequent use, including during the school day. (See 'Prevalence' above.)

Specific concerns about e-cigarette use by youth include:

Nicotine dependence – Use of e-cigarettes raises the risk of establishing nicotine

dependence in novice users, which could ultimately lead to combustible tobacco use.
This potential gateway effect is suggested by observations that e-cigarette use often
precedes conventional cigarette use [93-98]. As examples:

• A systematic review and meta-analysis of longitudinal studies among 17,389

adolescents and young adults aged 14 to 30 years showed that, compared with e-
cigarette never users, ever users had a higher probability of initiating cigarette
smoking (31 versus 8 percent, pooled adjusted odds ratio [OR] 3.50 [95% CI, 2.38-
5.16]) [96,99].

• In a prospective study of ninth-grade students, an association was seen between use

of e-cigarettes and other forms of tobacco and use of conventional cigarettes. After
adjusting for other risk factors for smoking, baseline e-cigarette use was associated
with a greater likelihood of using any combustible tobacco product (OR 2.7, 95% CI
2.0-3.7), including conventional cigarettes (OR 2.7, 95% CI 1.7-4.0), cigars (OR 4.9, 95%
CI 3.4-7.0), and hookahs (OR 3.3, 95% CI 2.3-4.6) [93].

Some of these findings may be related to the association between the predisposition of
an adolescent or young adult to smoke conventional cigarettes and their predisposition
to smoke e-cigarettes. However, analysis of psychosocial risk factors suggests that many
youth who use e-cigarettes are unlikely to have initiated tobacco smoking with
cigarettes [100].

Adverse effects – E-cigarette use raises the risk of adverse effects (eg, respiratory
symptoms), some of which have been reported particularly among youth [75,76,101].
(See 'Aerosol (also known as vapor) exposure' above and "E-cigarette or vaping product
use-associated lung injury (EVALI)".)

In addition, one internet survey of adolescents and young adults found that dual use of
cigarettes and e-cigarettes may be associated with an increased risk of self-reported
 infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the agent
that causes COVID-19 [102].

Normalizing smoking behavior – E-cigarette use may normalize smoking behavior,

which might contribute to conventional cigarette use. (See 'Renormalization of smoking
behavior' below.)

The long-term effects of nicotine exposure through e-cigarette use only, including the
effects of e-cigarette use during pregnancy, are not known. (See "Cigarette and tobacco
products in pregnancy: Impact on pregnancy and the neonate".)

Given the concerns that e-cigarette use may be a gateway to nicotine dependence among
adolescents, many public health authorities have recommended restricting e-cigarette
marketing and advertising to youth and banning flavorings, similar to strategies used to
reduce tobacco use by youth [103-106]. (See 'Regulatory status' below and "Prevention of
smoking and vaping initiation in children and adolescents", section on 'Advertising and media
influence'.)

There is ample evidence that e-cigarettes have been marketed using many of the strategies
previously used by tobacco companies to market conventional cigarettes to youth [107]. For
example, e-cigarettes have been commonly marketed with flavorings, which appeal to youths
and are banned in conventional cigarettes for this reason [22,108]. Exposure to e-cigarette
marketing has been associated with e-cigarette use among youth and young adults [109,110].

These issues are discussed in more detail separately. (See "Prevention of smoking and vaping
initiation in children and adolescents", section on 'Vaping nicotine'.)

ROLE IN SMOKING CESSATION

The available clinical trial evidence suggests that e-cigarettes may be effective as smoking
cessation aids, but more trials are needed to fully evaluate the safety and efficacy of e-
cigarettes for smoking cessation [1,7,111,112]. E-cigarettes may be more attractive to users
than other medications for smoking cessation because they look and taste more like
conventional cigarettes and permit the user to continue the hand-to-mouth ritual of smoking
[113]. In small studies, users of e-cigarettes reported reduced conventional cigarette cravings
and nicotine withdrawal symptoms [49,52]. However, there is the theoretical concern that e-
cigarettes could deter people from using smoking cessation medications with a known record
of safety and efficacy [57]. The American Thoracic Society recommends using proven
pharmacotherapy (ie, varenicline) rather than e-cigarettes for smoking cessation, and the US
Preventive Services Task Force concludes that the evidence is insufficient to fully evaluate the
benefits and harms of e-cigarettes for smoking cessation [111,114]. This is reviewed in detail
elsewhere. (See "Pharmacotherapy for smoking cessation in adults".)

Some people who have stopped using conventional cigarettes (and therefore are considered
to have quit) may or may not continue to use e-cigarettes [115]. However, discontinuing both
conventional cigarettes and e-cigarettes is advisable in order to avoid whatever longer-term
risk may be associated with e-cigarettes alone. The nature and magnitude of these risks are
uncertain at this time.

Efficacy — There is increasing evidence from randomized clinical trials that e-cigarettes are
effective for smoking cessation, although the long-term effectiveness and safety of e-
cigarettes compared with available pharmacotherapies is uncertain based upon limited high-
quality data [1,7,69,112]. In addition, most trials used earlier e-cigarette products, which may
limit the generalizability of trial results; newer e-cigarette devices allow for a higher nicotine
dose delivery, and these products may be more effective for smoking cessation than earlier
devices [116]. Further randomized trials, specifically using later e-cigarette devices, are
needed.

In published studies:

In a randomized trial including almost 900 people who smoked combustible tobacco
cigarettes in the United Kingdom, e-cigarettes were more effective in smoking cessation
than nicotine replacement therapy (NRT) at one year [115]. Participants were provided
either an e-cigarette starter pack or nicotine replacement products of their choice for
three months; all users were provided at least four weekly behavioral support sessions.
Biochemically proven cigarette abstinence rates at one year were 18.0 percent in the e-
cigarette user group and 9.9 percent in the NRT group (relative risk [RR] 1.83; 95% CI
1.20-2.58). Among those who were abstinent from cigarettes at one year, 80 percent of
those in the e-cigarette group were still using e-cigarettes, compared with 9 percent of
those in the NRT group who continued to use NRT. At one year, those in the e-cigarette
group had greater declines in the incidence of cough and phlegm production compared
with those in the NRT group. The safety of sustained e-cigarette use after quitting
conventional cigarette smoking represents harm reduction, although whether long-term
e-cigarette use among those who formerly smoked conventional cigarettes has any
negative long-term health consequences is not yet known.

In a randomized trial, approximately 375 Canadian adults who smoked conventional

cigarettes were assigned to receive nicotine e-cigarettes, non-nicotine e-cigarettes, or no
e-cigarettes for 12 weeks; all groups received counseling [7]. At 12 weeks, self-reported
smoking abstinence (point prevalence) was greater among those receiving nicotine e-
cigarettes plus counseling compared with counseling alone (22 versus 9 percent); the
 difference became nonsignificant by 24 weeks. Interpretation of the trial results,
however, is limited by methodologic issues, including early termination and
underpowering to detect study group differences.

In another randomized trial including over 650 adults who smoked conventional
cigarettes in New Zealand, participants were randomly assigned to nicotine-containing
(16 mg) e-cigarettes, nicotine-free e-cigarettes, or 21 mg nicotine patches [117]. At six
months, the biochemically verified smoking cessation rates were modest among all
groups (7 versus 4 versus 6 percent, respectively), and did not differ significantly.
Observed quit rates were lower than in most clinical trials, suggesting the study may
have had selection bias or other methodologic issues.

In a 2021 systematic review including 61 trials (of which 34 were randomized controlled
trials) and over 16,000 participants, there was moderate-certainty evidence that, among
those who smoke conventional cigarettes, quit rates were higher with the use of
nicotine e-cigarettes compared with NRT (RR 1.53, 95% CI 1.21-1.93), and that quit rates
were higher with the use of nicotine e-cigarettes compared with non-nicotine e-
cigarettes (RR 1.94, 95% CI 1.21-23.13); the certainty of all evidence was limited by
imprecision [112].

Observational trials provide evidence on how these devices are being used in actual practice
rather than in clinical trials. Results from observational studies are mixed [118-127]. Some
studies suggest an association between e-cigarette use and smoking cessation or reduction
[128]. However, multiple earlier studies have suggested that e-cigarette use is not associated
with higher rates of quitting or reducing smoking [118,122,129,130].

Smoking reduction — An individual will gain the most benefit if smoking is stopped entirely.
However, e-cigarettes might have the potential to reduce harm from tobacco-related diseases
by replacing or reducing conventional cigarette use [131-133]. There is little evidence to
support this hypothesis, and the degree to which smoking reduction must be achieved is not
established.

Replacing conventional cigarettes – The primary benefit hypothesized is a reduction in

the negative health consequences of conventional cigarette use for those who switch
completely to e-cigarettes. This could decrease conventional smoking rates at the
population level and should lead to a reduction in tobacco-attributable morbidity and
mortality. Theoretically, the reduction in tobacco-attributed morbidity and mortality
could be offset by any long-term adverse effects of e-cigarettes. (See 'Adverse health
effects' above.)

Dual use – If e-cigarettes lead to dual use (with conventional cigarettes), the individual
might still reduce their tobacco-attributable risk of chronic disease if they reduce the
 number of conventional cigarettes smoked. However, the relationship between the
amount of conventional cigarette smoking and disease is not strictly linear for all
conditions. For example, small amounts of smoke exposure can still increase risk for
coronary artery disease [134]. (See "Cigarette smoking and other possible risk factors for
lung cancer", section on 'Smoking reduction' and "Benefits and consequences of
smoking cessation", section on 'Questionable utility of smoking reduction'.)

PUBLIC HEALTH CONCERNS

In 2019, cases of e-cigarette or vaping product use associated lung injury (EVALI) were
reported. After epidemiologic investigation, evidence linked these cases primarily to vaping
tetrahydrocannabinol (THC) products that had been contaminated with vitamin E acetate
rather than to the use of commercially sold nicotine-containing e-cigarettes. (See "E-cigarette
or vaping product use-associated lung injury (EVALI)".)

Other potential impacts of e-cigarettes on public health include concerns include e-cigarettes'
appeal to youth, their potential to reverse gains in social norms about the acceptability of
cigarette smoking ("renormalization"), and the risk of dependence [1,135]. However,
dependence appears to be lower than for conventional tobacco cigarettes [1].

In addition, there have been increasing reports of poisoning in children related to e-cigarettes
and concerns about the possible effects of secondhand exposure to the aerosol. A US
Surgeon General’s report about the risks of e-cigarettes to youth highlights the importance of
preventing the initiation of nicotine use by adolescents [104].

Renormalization of smoking behavior — If e-cigarettes are allowed where cigarette

smoking is not, they could reverse the "de-normalization" of smoking behavior brought about
by the spread of smoke-free laws [2,136]. These laws are credited with contributing to
reducing smoking prevalence in the United States. Tobacco smoking could be "renormalized"
and the public health gains rolled back [137]. In theory, this might discourage the frequency
and success of quit attempts, encourage relapse among those who previously smoked, and
increase tobacco use initiation rates among youth and young adults. At present, there is no
evidence of smoking renormalization.

Nicotine poisoning — E-cigarette fluid contains highly concentrated liquid nicotine.

Exploratory ingestions in young children and intentional ingestions in adolescents and adults
have been associated with life-threatening toxicity and death. The clinical manifestations and
initial management of nicotine poisoning are provided in a rapid overview ( table 1) and
discussed in detail separately. (See "Nicotine poisoning (e-cigarettes, tobacco products, plants,
and pesticides)".)
Secondhand aerosol exposure — There are concerns about the potential health
consequences of secondhand exposure to e-cigarette aerosol due to increases in
environmental concentrations of nicotine and particulate matter [1]. However, passive
exposure to e-cigarette aerosol is expected to be less toxic to bystanders than conventional
cigarette smoke [1,138,139]. Aerosol released from e-cigarettes will depend on user
technique, temperature, e-cigarette device, and other factors [140].

There is limited evidence on the health effects of passive e-cigarette aerosol exposure. Passive
exposure to aerosol produces small increases in serum cotinine, comparable with that from
passive exposure to cigarette smoke [141]. (See 'Aerosol (also known as vapor) exposure'
above.)

REGULATORY STATUS

Regulation of e-cigarettes varies by country and is continually evolving. Multiple organizations

have recommended more government regulation [103,105,142-145]. They have called for
regulation that would treat e-cigarettes like conventional cigarettes, banning their use where
conventional cigarettes are banned and subjecting e-cigarettes' content, sales, and marketing
to regulatory constraints similar to those that apply to conventional cigarettes. Some have
suggested that taxation for e-cigarettes should be lower than for conventional cigarettes to
encourage adults who smoke conventional cigarettes to switch to e-cigarettes for harm
reduction [146].

Worldwide — The World Health Organization (WHO) report on e-cigarettes suggested that

regulations were needed to stop promotion of e-cigarettes to nonsmokers and young people,
minimize potential health risks to users and nonusers, stop unproven health claims about e-
cigarettes, and protect existing tobacco control efforts [142]. While the WHO acknowledged
that additional research on e-cigarettes was needed, it also emphasized the need to restrict e-
cigarette advertising and indoor use. Some groups have disagreed with the WHO report,
suggesting that the risks of e-cigarettes were overstated [147,148].

United Kingdom — In the United Kingdom, the Royal College of Physicians Tobacco Advisory
Group recommended a balanced regulatory approach that ensures product safety while
enabling and encouraging those who smoke to use e-cigarettes instead of tobacco to reduce
harm to health [149]. The report suggests that while e-cigarettes are not harmless, they are
likely less harmful than conventional cigarettes [150].

United States — The US Food and Drug Administration (FDA) does not regulate e-cigarettes
as medical products through the Center for Drug Evaluation and Policy (CDER), which
regulates nicotine replacement products such as nicotine patches. E-cigarette manufacturers
could apply to CDER for approval to market the devices as smoking cessation aids, but no
manufacturer has yet done so.

Instead, the FDA regulates e-cigarettes through its Center for Tobacco Products (CTP). Initially,
the 2009 Family Smoking Prevention and Tobacco Control Act granted the CTP the authority
to regulate cigarettes and smokeless tobacco but not other tobacco products, including cigars
and e-cigarettes [151]. In 2016, the regulation was amended to include any product "made or
derived from tobacco that is intended for human consumption," including e-cigarettes that
contain nicotine but not e-cigarettes that are nicotine-free [152].

FDA regulations require that e-cigarette manufacturers demonstrate that their products meet
the FDA standard of providing a net public health benefit or face the possibility of being
removed from the market [153]. The FDA voluntarily delayed enforcement of this standard
while it developed a process for conducting these evaluations. It required manufacturers to
submit an application for approval of e-cigarette products by September, 2020 [153]. In
September 2021, the FDA announced that it had acted on over 90 percent of applications,
issuing denials to over 900,000 flavored products due to health concerns related to their
popularity among youth [154]. Subsequently, in October 2021, the FDA for the first time
authorized the marketing of some electronic nicotine delivery system (ENDS) products, while
noting that this ruling “does not mean these products are safe or ‘FDA approved’” [155].

The FDA also requires manufacturers, and in many cases retailers ("vape shops") where e-
cigarette devices are modified and sold, to disclose the ingredients in their products and
demonstrate that they are safe [156,157].

The FDA prohibits the sale of tobacco and e-cigarette products to those aged <21 years, sales
in vending machines (except in adult-only venues), and distribution of free samples [158]. In
addition, there are federal regulations to minimize the risk of exposure of youth to e-
cigarettes, including prohibition of sales of flavored liquids (other than menthol or tobacco) in
devices that use pre-filled cartridges [159,160]. Flavored e-cigarette liquids, however, are
available for sale in vape shops for use in devices that have refillable tanks. In addition, this
ban did not apply to flavored disposable e-cigarettes, which have become increasingly
popular among youth. Among high school e-cigarette users, for example, the percentage who
reported using disposable e-cigarettes increased from 2.4 percent in 2019 to 26.5 percent in
2020 [14]. The FDA has attempted to remove these flavored disposable e-cigarettes from the
market but, despite this effort, many remain on the market [161,162].

A number of states and many municipalities have banned the use of e-cigarettes in areas
where cigarette smoking is also completely banned (with limited exceptions in a few states),
and additional states and municipalities have banned e-cigarette use in other venues [163]. E-
cigarette use is also banned on airplanes [164].
Other countries — E-cigarettes have been banned in some countries [57]. In Europe, the
European Parliament approved a directive that regulates nicotine-containing e-cigarettes with
concentrations up to 20 mg/mL as tobacco products [165]. E-cigarettes with higher nicotine
concentrations are regulated as medical devices. The directive includes regulation for the
maximum amount of nicotine in e-cigarette liquids and requires child tamper-proof
packaging.

COUNSELING FOR PATIENTS

In the absence of clear outcomes data on the health consequences of e-cigarette use and
their efficacy for smoking cessation, evidence-based definitive recommendations cannot be
made [166].

Information for counseling patients on what is known related to e-cigarettes is available from
some medical societies’ documents on e-cigarettes. Policy statements from the American
Cancer Society, American Heart Association, and other groups provide guidance on
addressing e-cigarette use in clinical practice [143,144,167-169]. The Centers for Disease
Control and Prevention (CDC) also provides guidance to clinicians and the public about
electronic cigarettes [170].

For children, a report by the Surgeon General, “Know the risks, e-cigarettes and young
people,” includes information sheets that clinicians may use to educate patients as well as
a tip sheet for parents [104]. Information for adolescents and their caregivers about e-
cigarettes is available from the CDC website, including content about health risks and
other frequently asked questions and advice for caregivers on how to keep kids e-
cigarette-free [171].

Given the available evidence, we discuss these points with patients in a conversation about e-
cigarettes:

Recreational use of e-cigarettes should not be initiated; non-smokers should not start
using or use e-cigarettes [172].

For those who smoke combustible tobacco products, a complete switch to using
nicotine-containing e-cigarettes is likely to be less harmful, but the health risks of long-
term e-cigarette use are not yet known. Therefore, those who switch to e-cigarettes
should eventually plan to quit e-cigarette use as well, so long as that does not lead to
relapse (ie, smoking combustible cigarettes). Dual use of combustible cigarettes and e-
cigarettes is not likely to substantially reduce the risk of tobacco-related disease.
 E-cigarette or vaping product use associated lung injury (EVALI) has been associated
with vaping of tetrahydrocannabinol (THC) products contaminated by vitamin E acetate
rather than commercially purchased nicotine-containing e-cigarettes. E-cigarette
products should not be bought “off the street,” adulterated, or altered (ie, should not
have any substances added to the commercially manufactured product) [59]. (See "E-
cigarette or vaping product use-associated lung injury (EVALI)".)

For those who smoke conventional cigarettes who are interested in using e-cigarettes for
smoking cessation, we also discuss the following:

No e-cigarette has been approved by the US Food and Drug Administration (FDA) for
smoking cessation, and the FDA has not endorsed their safety or efficacy for smoking
cessation.

People should be congratulated on their interest in smoking cessation and reminded

that safe and effective treatments to help them reach that goal already exist.

Individuals should be encouraged to try the FDA-approved products first because of the
lack of evidence regarding the practical effectiveness of e-cigarettes in promoting
smoking cessation. Those who previously failed conventional treatments should be
assessed for proper medication use and/or consider second-line therapies. (See
"Pharmacotherapy for smoking cessation in adults".)

If individuals are unwilling to use FDA-approved medications for smoking cessation, it is

up to the clinician's judgment whether to support the use of e-cigarettes. Smokers
should be made aware of the uncertainty about their safety and efficacy as therapeutic
devices. People who choose to use e-cigarettes to quit should be advised to switch
completely to e-cigarettes and use them regularly as substitutes for tobacco cigarettes,
rather than using e-cigarettes while continuing to smoke tobacco cigarettes.

Regardless of the method chosen, it is important for the individual to understand that
their efforts to become smoke-free will continue to receive the clinician's strongest
support and assistance.

The use of e-cigarettes should not be permitted in hospitals or health care facilities.
Conventional cigarettes are not allowed in these venues. Nicotine replacement products, not
e-cigarettes, should be used to manage nicotine withdrawal symptoms in hospitalized
patients. (See "Pharmacotherapy for smoking cessation in adults", section on 'Nicotine
replacement therapy' and "Pharmacotherapy for smoking cessation in adults", section on
'Hospitalized patients'.)
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Smoking cessation, e-
cigarettes, and tobacco control".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Vaping (The Basics)")

SUMMARY AND RECOMMENDATIONS

E-cigarette devices and liquids – Electronic cigarettes (e-cigarettes) are electronic

devices that usually deliver nicotine; they consist of a cartridge containing a liquid, an
atomizer (vaporization chamber with a heating element), and a battery. The user
activates the atomizer, which heats the liquid and produces an aerosol (sometimes
referred to as a vapor) to inhale ( figure 1 and figure 2). Across all brands, the main
components in nicotine e-cigarette liquids are nicotine, propylene glycol or glycerol, and
flavorings. A variety of other compounds have also been identified. (See 'Electronic
nicotine delivery systems' above.)

Prevalence and patterns of use – The use of e-cigarettes by adults has increased over
the past decade, and while it had more significantly increased among middle and high
school students, the prevalence of use among youth appears to be declining. Most adult
e-cigarette users also currently smoke conventional tobacco cigarettes. A majority of e-
 cigarette users perceive them to be a tool to quit or reduce their smoking. (See
'Prevalence and patterns of use' above.)

Adverse health effects – Potential adverse effects of e-cigarettes are related to

exposure to nicotine as well as to other aerosol components produced by the devices
and risks of the actual device. No observational data examining the long-term risk of
cancer from e-cigarettes exist; however, the risk is likely to be much lower in adults who
use e-cigarettes than in those who smoke conventional cigarettes. (See 'Adverse health
effects' above.)

In 2019, the Centers for Disease Control and Prevention (CDC) reported over two
thousand cases of severe acute lung illnesses (e-cigarette, or vaping, product use
associated lung injury [EVALI]) linked to the use of e-cigarette devices to aerosolize
substances for inhalation. Vitamin E acetate has been linked to EVALI, although the exact
cause has yet to be determined. (See 'Aerosol (also known as vapor) exposure' above and
"E-cigarette or vaping product use-associated lung injury (EVALI)".)

Role of e-cigarettes in smoking cessation – For adults, the evidence that e-cigarettes
are effective smoking cessation aids is growing, but the risks remain uncertain.
Clinicians should encourage adults who inquire about quitting smoking to use smoking
cessation aids approved by the US Food and Drug Administration (FDA), including
pharmacotherapy as a first choice. For adults who have quit smoking but are using e-
cigarettes, clinicians should strongly advise them not to return to smoking cigarettes but
might consider offering nicotine replacement products as alternatives if the individual
wishes to stop using e-cigarettes. (See 'Role in smoking cessation' above and 'Counseling
for patients' above.)

Public health concerns – Public health concerns regarding e-cigarettes include EVALI as
well as the potential to increase youth initiation of tobacco products ( figure 3 and
figure 4), renormalize tobacco use in places where cigarette smoking is not
acceptable, and lead to nicotine dependence. Accidental nicotine poisoning in children
has been reported. The health effects of secondhand aerosol exposure are unknown.
(See 'Concerns related to youth and nonsmokers' above and 'Public health concerns'
above.)

Patient counseling – Recreational use of e-cigarettes should not be initiated; non-

smokers should not start using or use e-cigarettes. E-cigarette products should not be
bought "off the street," adulterated, or altered (ie, should not have any substances
added to the commercially manufactured product). (See 'Counseling for patients' above.)

ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Stephen Rennard, MD, and Sara Kalkhoran, MD,
MAS, who contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Terms of Use.

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se of e-cigarette, or vaping, products. Available at: https://www.cdc.gov/tobacco/basic_inf
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171. Centers for Disease Control and Prevention. Quick facts on the risks of e-cigarettes for ki
ds, teens, and young adults. Available at: https://www.cdc.gov/tobacco/basic_informatio
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s.html (Accessed on October 01, 2019).
Topic 98400 Version 82.0
GRAPHICS

E-cigarette

Graphic 98585 Version 1.0

Types of e-cigarette (vaping) devices

Reproduced from: Centers for Disease Control and Prevention. Quick facts on the risk of e-cigarettes for kids, teens, and young adu
Available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-an
Young-Adults.html (Accessed on January 15, 2020).

Graphic 126552 Version 1.0

Current tobacco product use among middle school students (NYTS, 2011-2022

Dashed and dotted lines represent changes in survey methodology and may affect the comparability of re
collection included a new electronic mode of survey administration as well as presentation of tobacco ima
terminated early due to the COVID-19 pandemic; and in 2021, many students participated in distance lear
administered both remotely and in school settings.

NYTS: National Youth Tobacco Survey.

* Any tobacco product use is defined as ever use of 1 or more of the following tobacco products: e-cigaret
(chewing tobacco, snuff, and dip; snus; and dissolvable tobacco products), hookahs, nicotine pouches, hea
bidis (small brown cigarettes wrapped in a leaf).

¶ These are new categories and do not have data for previous years.

Δ Any combustible tobacco product use was defined as ever use of 1 or more of the following tobacco pro
tobacco, or bidis.

◊ Multiple tobacco product use was defined as ever use of 2 or more of the following tobacco products: e
tobacco, hookahs, nicotine pouches, heated tobacco products, pipe tobacco, or bidis.

§ Smokeless tobacco was defined as chewing tobacco, snuff, dip, snus, or dissolvable tobacco products.

Data from:
1. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco Product Use and Associated Factors Among Middle and High School Stud
2019; 68:1.
2. Gentzke AS, Wang TW, Jamal A, et al. Tobacco product use among middle and high school students – United States, 2020. MM
 3. Gentzke AS, Wang TW, Cornelius M, et al. Tobacco product use and associated factors among middle and high school studen
2021. MMWR Surveill Summ 2022; 71:1.
4. Centers for Disease Control and Prevention. Smoking and tobacco use: Youth data. Available at:
https://www.cdc.gov/tobacco/data_statistics/mmwrs/bytopic/youth_data/index.htm (Accessed on April 20, 2022).
5. Park-Lee E, Ren C, Cooper M, et al. Tobacco product use among middle and high school students – United States, 2022. MMW

Graphic 126349 Version 3.0

Current tobacco product use among high school students (NYTS, 2011-2022)

Dashed and dotted lines represent changes in survey methodology and may affect the comparability of re
collection included a new electronic mode of survey administration as well as presentation of tobacco ima
terminated early due to the COVID-19 pandemic; and in 2021, many students participated in distance lear
administered both remotely and in school settings.

NYTS: National Youth Tobacco Survey.

* Any tobacco product use is defined as ever use of one or more of the following tobacco products: e-ciga
tobacco (chewing tobacco, snuff, and dip; snus; and dissolvable tobacco products), hookahs, nicotine pou
tobacco, or bidis (small brown cigarettes wrapped in a leaf).

¶ These are new categories and do not have data for previous years.

Δ Any combustible tobacco product use was defined as ever use of one or more of the following tobacco p
pipe tobacco, or bidis.

◊ Multiple tobacco product use was defined as ever use of two or more of the following tobacco products
smokeless tobacco, hookahs, nicotine pouches, heated tobacco products, pipe tobacco, or bidis.

§ Smokeless tobacco was defined as chewing tobacco, snuff, dip, snus, or dissolvable tobacco products.

Data from:
1. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco Product Use and Associated Factors Among Middle and High School Stud
2019; 68:1.
2. Gentzke AS, Wang TW, Jamal A, et al. Tobacco product use among middle and high school students – United States, 2020. MM
 3. Gentzke AS, Wang TW, Cornelius M, et al. Tobacco product use and associated factors among middle and high school studen
2021. MMWR Surveill Summ 2022; 71:1.
4. Park-Lee E, Ren C, Cooper M, et al. Tobacco product use among middle and high school students – United States, 2022. MMW

Graphic 126348 Version 3.0

Nicotine poisoning: Rapid overview of emergency management

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-
1222 for the nearest regional poison control center. Contact information for poison control centers
around the world is available at the WHO website and in the UpToDate topic on regional poison
control centers (society guideline links).

Clinical presentation

Toxicity develops rapidly (within minutes to 1 hour) after ingestion or dermal exposure to
concentrated nicotine products (eg, e-cigarette cartridges or industrial, agricultural, or
insecticide exposures) or after ingestion of >0.1 mg/kg of tobacco or nicotine products.
Toxicity may be delayed after ingestion or cutaneous application of a transdermal nicotine
patch or dermal exposure to wet tobacco plants (green tobacco sickness).

Acute toxicity

Toxicity is caused by nicotine binding to nicotinic acetylcholinesterase receptors in the brain, the
spinal cord (postganglionic sympathetic and parasympathetic neurons), and at the
neuromuscular junction. Patients may rapidly progress from mild to moderate or severe toxicity:
Mild:
Nausea and vomiting
Salivation
Drowsiness
Hyperactivity (for infants, fussy but consolable)
Tachycardia
Pallor
Diaphoresis
Dizziness
Moderate:
Hypertension
Bronchorrhea, wheezing, repeated vomiting, and/or diarrhea
Tachypnea secondary to bronchorrhea
Tremors
Muscle fasciculations
Ataxia
Confusion, agitation, lethargy, irritability (for infants, inconsolable crying)
Severe:
Bradyarrhythmias, cardiac arrest
Hypotension
Respiratory failure secondary to muscle paralysis
Seizures
Coma

Diagnostic evaluation
 Nicotine poisoning is a clinical diagnosis based upon a history of nicotine or tobacco exposure
and clinical features; definitive laboratory testing is not available in a timely fashion but may be
indicated to confirm exposure (obtain blood and urine samples for cotinine and other nicotine
metabolites).

Obtain ancillary studies based upon degree of toxicity:

Asymptomatic or mild toxicity (monitor closely for worsening toxicity):
Exploratory or unintentional exposure: No studies necessary
Intentional exposure for self-harm: Acetaminophen and salicylate plasma levels
Moderate to severe:
ECG
Rapid plasma glucose
Arterial or venous blood gas
Electrolytes
Serial measures of creatine kinase and urinalysis for patients with muscle fasciculations,
seizures, and/or paralysis to assess presence of rhabdomyolysis
Plasma and red blood cell cholinesterase (to differentiate from organophosphate or
carbamate poisoning)
In patients with seizures and all pediatric patients, urine screening for drugs of abuse

Management
There is no antidote for nicotine poisoning; treatment is supportive.

PPE:
No special PPE is needed for nicotine ingestion.
For dermal exposures with concentrated nicotine products or industrial, agricultural, or
insecticide exposures, providers should wear a waterproof gown, gloves, and eye
protection.

Decontamination: Perform decontamination in conjunction with stabilization of airway,

breathing, circulation, and other emergency therapies.
Dermal exposure (eg, spilled e-cigarette liquid, nicotinic pesticides, or damp plant material
[green tobacco sickness]):
Wipe off any liquid on the skin.
Remove all clothing and transdermal nicotine patches.
Cover any open wounds and then irrigate skin with lukewarm water with mild soap,
rinse with lukewarm water, pat dry, and cover the patient with warmed linens/blankets
to prevent hypothermia (use beside warmer in infants and young children).
Large ingestion of concentrated liquid nicotine: After assuring the airway is protected as
needed, nasogastric aspiration of stomach contents may be attempted although efficacy is
uncertain. Within 1 hour of a potentially toxic ingestion of nicotine or a tobacco product or
within 3 hours of ingestion of a transdermal nicotine patch, administer activated charcoal
without sorbitol 1 g/kg (maximum single dose 50 g).

Moderate to severe poisoning

Cholinergic toxicity:
 Deliver 100% oxygen via facemask; timely intubation may be required for coma, seizures,
skeletal muscle weakness/paralysis, or bronchorrhea not responsive to atropine; avoid
succinylcholine.
Atropine 0.01 to 0.02 mg/kg IV/IM up to 2 mg maximum single dose; repeat every 3 to 5
minutes, targeting drying of bronchial secretions and clearing of wheezing; tachycardia is
not a contraindication to atropine.
Inhaled ipratropium bromide 0.5 mg by nebulizer for wheezing.

Shock or cardiac arrhythmias:

Treat hypotension with rapid infusion of isotonic saline or balanced crystalloid solutions
(eg, lactated Ringer) according to the degree of shock and presence of pre-existing
conditions (eg, heart failure); provide continuous infusion of norepinephrine or epinephrine
for fluid-refractory shock.
Sinus bradycardia with hypotension or bradyarrhythmias: Atropine as above; patients
unresponsive to atropine should receive treatment according to ACLS and PALS algorithms
for bradycardia.
Tachyarrhythmias (SVT or VT): Treat according to ACLS and PALS algorithms.

Seizures:
Benzodiazepines (eg, lorazepam 0.1 mg/kg up to 4 mg per dose, repeat every 5 minutes as
needed); if additional anticonvulsant is needed, phenobarbital is preferred; avoid
fosphenytoin or phenytoin. For refractory convulsive status epilepticus, continuous
midazolam infusion is preferred.

Paralysis:
Pralidoxime is ineffective for nicotine poisoning. If there is no clear history of nicotine
exposure or organophosphate exposure is also suspected, a trial loading dose of 30 mg/kg
(maximum single dose 2 g) given IV over 15 to 30 minutes is reasonable. Refer to UpToDate
content on organophosphate poisoning.

Rhabdomyolysis:
Continuous infusion of IV normal saline to maintain urine output of 200 to 300 mL/hour
(adults) and urinary alkalinization.

Asymptomatic exposure or mild poisoning

Closely monitor for progression to moderate or severe poisoning.

Observe patients with transdermal patch ingestion for 24 hours because toxicity may be
delayed.
Patients who are asymptomatic after 6 hours of observation may be discharged home or, for
patients who intended self-harm, cleared for mental health evaluation.

ECG: electrocardiogram; PPE: personal protective equipment; IV: intravenous; IM: intramuscular;
ACLS: advanced cardiac life support; PALS: pediatric advanced life support; SVT: supraventricular
tachycardia; VT: ventricular tachycardia.

Graphic 138390 Version 3.0

Contributor Disclosures
Nancy A Rigotti, MD Grant/Research/Clinical Trial Support: Achieve Life Sciences [Smoking cessation].
Consultant/Advisory Boards: Achieve Life Sciences [Smoking cessation]. All of the relevant financial
relationships listed have been mitigated. Krishna P Reddy, MD No relevant financial relationship(s) with
ineligible companies to disclose. Mark D Aronson, MD No relevant financial relationship(s) with
ineligible companies to disclose. Umur Hatipoglu, MD, MBA No relevant financial relationship(s) with
ineligible companies to disclose. Sara Swenson, MD No relevant financial relationship(s) with ineligible
companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
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