Science Policy

Electronic Nicotine Delivery Systems

R.C. Moffat, K.M. Byrd, X. Li, Y-H. Yu, C.H. Fox, M.K.S. Charles-Ayinde


The American Association for Dental, Oral, and Craniofacial Research (AADOCR) acknowledges the rising public health concerns associated with electronic nicotine delivery systems (ENDS).  Nicotine is the main psychoactive, chemically addictive component in tobacco and nicotine replacement therapy in various forms (gums, lozenges, and patches) has been used as smoking cessation tools for decades.1 As ENDS are a relatively new technology, the AADOCR encourages a comprehensive, measured, and deliberative approach to the consideration of the most recent high-quality, evidence-based research prior to the implementation of public policy. 

ENDS are handheld devices containing a heating element that produce an aerosol from a liquid solution that often contains nicotine,carriersolvents (e.g. propylene glycol or vegetable glycerine), and flavoring chemicals.1 The act of inhaling and exhaling this aerosol is often called “vaping,” although technically, vaping can occur with nicotine-free solutions.2 ENDS solutions come in a variety of flavors and nicotine concentrations.3 The term “e-cigarette” is often used synonymously with ENDS; however, e-cigarettes do not always contain nicotine. Currently, about ninety-nine percent of e-cigarettes sold contain nicotine.4


Although using ENDS devices have been marketed as a tobacco smoking cessation strategy,3,5 further research is necessary. The Cochrane review on the topic showed moderate-certainty evidence that using e-cigarettes with nicotine increased quit rates compared to nicotine replacement therapy to the level of three additional quitters per 100.6 However, other research has shown no differences when the cessation rates of ENDS, nicotine replacement therapy (NRT), and non-NRT medication were compared18, as well as inconclusive results on the effectiveness of ENDS as a tobacco cessation aid19,20,21.


Due to the novelty of ENDS, the potential oral health consequences of ENDS device use are uncertain. While evidence is limited, studies have revealed that oral health harms of e-cigarettes include modulation of the host oral microbiome causing increased gum inflammation, damage to tooth enamel from device explosion, and problematic changes to oral cells when exposed to e-cigarettes.1,7,8,9 To the contrary, research has shown that e-cigarette users had comparable oral health to non-users10 and that the oral health impacts of ENDS, as currently understood, are less than the known, considerably harmful, oral health impacts of tobacco smoking.7  Overall, studies on e-cigarettes reveal potential health harms22,23, underscoring the need for more research.  


Since 2014, ENDS, specifically e-cigarettes, have been the most commonly used tobacco-derived product among U.S. youth11. In 2022, about 1 in 10 (2.5 million) U.S. middle and high school students reported current e-cigarette use.12 Between 2017 and 2019, nicotine vaping increased by 9.0, 14.9, and 16.5 percentage points in 8th, 10th, and 12th grades, respectively.13  ENDS products have the potential to serve as an entry point for use of other nicotine-containing products.14 Adolescents who use e-cigarettes are 3.5 times more likely to report using traditional cigarettes and 4 times more likely to continue their use past 30 days.15 Enticing flavors increase the appeal of ENDS product use to children and adolescents.16 Dozens of unique flavors of ENDS products exist, including fruit and candy flavors.17 


In addition to the health consequences for the ENDS user, the effects of the exhaled aerosols on others are also a concern. Further research is needed on the health effects of secondary exposure to ENDS aerosols.


Based on current evidence-based scientific evidence, AADOCR supports the following recommendations:

  1. The AADOCR opposes promoting the use of ENDS products. Efforts should be made to educate the public on the current evidence-based research regarding ENDS, the potential health problems of ENDS use, and the prevention of ENDS use among children and adolescents. 
  2. AADOCR welcomes continued research to elucidate further the health effects of ENDS use as well as the health effects upon non-users exposed to exhaled aerosols. Additionally, research regarding the use of ENDS as a smoking cessation strategy should be a priority.
  3. AADOCR supports collaboration with other organizations, healthcare providers, and institutions to inform the public of ENDS-related research findings and to advocate for appropriate public policy.
  4. AADOCR supports national, state, and local legislation that eliminates ENDS advertising, promotions, and sales that appeal to or influence children and adolescents. Additionally, AADOCR also supports the continued enactment and enforcement of state and local clean indoor air policies or ordinances prohibiting smoking, including vaping, in public places.

The AADOCR will continue to thoroughly review the scientific literature regarding ENDS and updates to this position statement will be made as supported by the literature.


Author Contributions
R.C.M. and K.M.B. contributed to the design, interpretation, and drafting, of the position statement. X. Li, C.H.F., M.K.S.C.A, and all members of the IADR Science Information Subcommittee critically revised the statement. All authors gave final approval and agree to be accountable for all aspects of the work.
 

Acknowledgments 
The members of the 2022 AADOCR Science Information Subcommittee were K.M. Byrd, X. Li, R.C. Moffat, and Y-H. Yu. The AADOCR Science Information Committee thanks all members of the Subcommittee for providing subject matter expertise during the drafting of the policy statement.
The authors received no financial support and declare no potential conflicts of interest concerning the authorship of this article.


References:

  1. Holliday R, Chaffee BW, Jakubovics NS, Kist R, Preshaw PM. (2021). Electronic Cigarettes and Oral Health. J Dent Res. 100(9):906-13. 
  2. Centers for Disease Control and Prevention. (2022). Smoking and Tobacco Use: About Electronic Cigarettes (E-Cigarettes). Retrieved from:  https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html Accessed August 23, 2022.
  3. U.S. Food and Drug Association. E-Cigarettes, Vapes, and Other Electronic Nicotine Delivery Devices (ENDS). Retrieved from: https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends Accessed September 15, 2022.
  4. West, R., and Cox, S. (2022). The 1988 US Surgeon General's Report Nicotine Addiction: How Well Has It Stood Up to Three More Decades of Research? Addiction. 117(8), 2346-2350.
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  16.  Jenssen BP, and Walley SC. (2019). E-Cigarettes and Similar Devices. Pediatrics. 143(2):e20183652.
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  18.  Kaplan B, Galiatsatos P, Breland A, Eissenberg T, and Cohen JE. (2021). Effectiveness of ENDS, NRT and Medication for Smoking Cessation Among Cigarette-Only Users: A Longitudinal Analysis of PATH Study Wave 3 (2015–2016) and 4 (2016–2017), Adult Data. Tobacco Control. 0:1-6e056448.
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(Adopted 2023)