E-cigarettes: promise or threat?


  • Arun C. Nachiappan Nottingham University Hospitals, Trent Foundation School, United Kingdom
  • T. S. Selvavinayagam Institute of Community Medicine, Madras Medical College, Chennai, Tamil Nadu, India




Electronic cigarette, ENDS, Tobacco, Cigarette smoking, Smoking cessation


Use of the electronic cigarette or electronic nicotine delivery system (ENDS) is increasing globally. Its vapour delivers nicotine without the 6000 odd chemicals released during cigarette smoking and the associated harm. Experts are divided on whether ENDS promise reduction in tobacco use or threaten tobacco control. This review presents up-to-date evidence. Two trials showed an increase in cessation, but not a reduction in cigarette use. Eight cohort studies showed no increase in cessation, and two cohort studies and a recent trial showed an increased reduction in cigarette use. A US population study showed association between ENDS use and smoking cessation. Nicotine addiction and potential harm to non-smokers who use ENDS are key concerns. Nicotine affects lung and brain development. An increase in accidental poisoning, though mild, is reported in children. No significant short term health effects are reported. When heated, ENDS may emit potential toxic and carcinogenic substances such as aldehydes, acrolein, flavouring agents etc. at very low levels - but their long term impact is not known. ENDS bring potential benefits to smokers, but there are concerns about their potential for nicotine addiction, gateway effect and renormalisation of smoking. However, in the UK and the US, a rise in ENDS use is associated with a fall in the prevalence of smoking. Countries differ in their approach to ENDS. India seems to be edging towards a total ban. India should collect local data and conduct research to monitor the impact and make informed, evidence based decisions, where needed. 

Author Biography

Arun C. Nachiappan, Nottingham University Hospitals, Trent Foundation School, United Kingdom

Foundation Year 1 

Nottingham University Hospitals

Trent Foundation School


Ministry of Health and Family Welfare, Government of India. Report on Tobacco Control in India, 2004. Available at: http://www.who. int/fctc/reporting/Annex6_Report_on_Tobacco_Control_in_India_2004.pdf. Accessed on 31 July 2017.

Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey (GATS) India Report 2009-2010. Available at: http://www.searo.who.int/tobacco/documents/2010-pub2.pdf?ua=1. Accessed 25th July 2017

Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey (GATS) India Report 2016-2017. Available at: http://www.searo.who.int/india/mediacentre/events/2017/gats2_india.pdf?ua=1. Accessed 31st July 2017.

Conference of the Parties to the WHO Framework Convention on Tobacco Control. Electronic Nicotine Delivery Systems: A Report by WHO, 2014. Available at: http://apps.who.int/gb/fctc/ PDF/cop6/FCTC_COP6_Report-en.pdf. Accessed on 31 July 2017.

Hummel K, Hoving C, Nagelhout G, de Vries H, van den Putte B, Candel M, et al. Prevalence and reasons for use of electronic cigarettes among smokers: Findings from the International Tobacco Control (ITC) Netherlands Survey. Int J Drug Policy. 2015;26:601–8.

Biener L, Hargraves J. A Longitudinal Study of Electronic Cigarette Use Among a Population-Based Sample of Adult Smokers: Association With Smoking Cessation and Motivation to Quit. Nicotine Tob Res. 2015;17:127–33.

El Dib R, Suzumura E, Akl E, Gomaa H, Agarwal A, Chang Y, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis. BMJ Open. 2017;7:e012680.

McNeill A, Brose L, Calder R, Hitchman S, Hajek P, et al. E-cigarettes: an evidence update. A report commissioned by Public Health England, 2015. Available at: https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf. Accessed on 1 August 2017.

Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014;109:1531–40.

Shi Y, Pierce J, White M, Vijayaraghavan M, Compton W, Conway K, et al. E-cigarette use and smoking reduction or cessation in the 2010/2011 TUS-CPS longitudinal cohort. BMC Public Health. 2016;16:1105.

Zhu S, Zhuang Y, Wong S, Cummins S, Tedeschi G. E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. BMJ. 2017;358:3262.

Tseng T, Ostroff J, Campo A, Gerard M, Kirchner T, Rotrosen J. A Randomized Trial Comparing the Effect of Nicotine Versus Placebo Electronic Cigarettes on Smoking Reduction Among Young Adult Smokers. Nicotine Tob Res. 2016;18:1937–43.

England L, Bunnell R, Pechacek T, Tong V, McAfee T. Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate. Am J Prev Med. 2015;49:286–93.

Benowitz N. The Role of Nicotine in Smoking-Related Cardiovascular Disease Prev Med (Baltim). 1997;26:412–7.

Murray R, Bailey W, Daniels K, Bjornson W, Kurnow K, Connett J, et al. Safety of nicotine polacrilex gum used by 3,094 participants in the Lung Health Study. Lung Health Study Res Group Chest. 1996;109:438–45.

United States of America. Public Health Service. Office of the Surgeon General. How tobacco smoke causes disease : the biology and behavioral basis for smoking-attributable disease : a report of the Surgeon General, 2010. (U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General).

Centres for Disease Control and Prevention. ATSDR - Toxic Substances - Propylene Glycol, 2017. Available at: https://www.atsdr.cdc.gov/ substances/toxsubstance.asp?toxid=240. Accessed on 31 July 2017.

Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead L, Hajek P. Electronic cigarettes for smoking cessation. 2014;9:CD010216.

Hua M, Talbot P. Potential health effects of electronic cigarettes: A systematic review of case reports. Prev Med Reports. 2016;4:169–78.

Public Health England. National Poisons Information Service: Report 2013/14. Available at: http://www.npis.org/NPISAnnualReport2013-14.pdf. Accessed on 1 August 2017.

Arnaout A, Khashaba H, Dobbs T, Dewi F, Pope-Jones S, Sack A, et al. The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature. Burns. 2017;43(4):e1-e6.

E-cigarette aerosol contains 6 times LESS formaldehyde than tobacco cigarette smoke, 2014. Available at: http://www.ecigarette-research.com/ web/index.php/2013-04-07-09-50-07/2014/188-frm-jp. Accessed on 31 July 2017.

Farsalinos K, Voudris V, Poulas K. E-cigarettes generate high levels of aldehydes only in ‘dry puff’ conditions. Addiction. 2015;110:1352–6.

Hecht S, Carmella S, Kotandeniya D, Pillsbury M, Ransom B, Vogel R, et al. Evaluation of toxicant and carcinogen metabolites in the urine of e-cigarette users versus cigarette smokers. Nicotine Tob Res. 2015;17:704–9.

McRobbie H, Phillips A, Goniewicz M, Smith K, Knight-West O, Przulj D, et al. Effects of Switching to Electronic Cigarettes with and without Concurrent Smoking on Exposure to Nicotine, Carbon Monoxide, and Acrolein. Cancer Prev Res. 2015;8:873–8.

Chen J, Bullen C, Dirks K. A Comparative Health Risk Assessment of Electronic Cigarettes and Conventional Cigarettes. Int J Environ Res Public Health. 2017;14:382.

Nutt D, Phillips L, Balfour D, Curran V, Dockrell M, Foulds J, et al. Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach. Eur Addict Res. 2014;20:218–25.

Williams M, Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One. 2013;8:e57987.

Pisinger C, Døssing M. A systematic review of health effects of electronic cigarettes. Prev. Med. (Baltim). 2014;69:248–60.

Palazzolo D. Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review. Front. public Heal. 2013;1:56.

Cardinale A, Nastrucci C, Cesario A, Russo P. Nicotine: specific role in angiogenesis, proliferation and apoptosis. Crit. Rev Toxicol. 2012;42:68–89.

Sleiman M, Logue J, Montesinos V, Russell M, Litter M, Gundel L, et al. Emissions from Electronic Cigarettes: Key Parameters Affecting the Release of Harmful Chemicals. Environ Sci Technol. 2016;50:9644–51.

Kim H, Shin H. Determination of tobacco-specific nitrosamines in replacement liquids of electronic cigarettes by liquid chromatography–tandem mass spectrometry. J Chromatogr. 2013;1291:48–55.

Bahl V, Lin S, Xu N, Davis B, Wang Y, Talbot P. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reprod Toxicol. 2012;34, 529–37.

Romagna G, Allifranchini E Bocchietto E, Todeschi S, Esposito M, Farsalinos K. Cytotoxicity evaluation of electronic cigarette vapor extract on cultured mammalian fibroblasts (ClearStream-LIFE): comparison with tobacco cigarette smoke extract. Inhal Toxicol. 2013;25:354–61.

Goniewicz M, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014;23:133–9.

Behar R, Davis B, Wang Y, Bahl V, Lin S, Talbot P. Identification of toxicants in cinnamon-flavored electronic cigarette refill fluids. Toxicol In Vitro. 2014;28:198–208.

Grana R, Benowitz N, Glantz S. E-Cigarettes: A Scientific Review. Circulation. 2014;1291972–86.

Goniewicz M, Gupta R, Lee Y, Reinhardt S, Kim S, Kim B, et al. Nicotine levels in electronic cigarette refill solutions: A comparative analysis of products from the U.S., Korea, and Poland. Int J Drug Policy. 2015;26:583–8.

Ballbè M, Martínez-Sánchez J, Sureda X, Fu M, Pérez-Ortuño R, Pascual J, et al. Cigarettes vs. e-cigarettes: Passive exposure at home measured by means of airborne marker and biomarkers. Environ Res. 2014;135:76–80.

Bush D, Goniewicz M. A pilot study on nicotine residues in houses of electronic cigarette users, tobacco smokers, and non-users of nicotine-containing products. Int J Drug Policy. 2015;26:609–11.

Czogala J, Goniewicz M, Fidelus B, Zielinska-Danch W, Travers M, Sobczak A. Secondhand Exposure to Vapors From Electronic Cigarettes. Nicotine Tob Res. 2014;16:655–62.

Schripp T, Markewitz D, Uhde E, Salthammer T. Does e-cigarette consumption cause passive vaping? Indoor Air. 2013;23:25–31.

Flouris A, Chorti M, Poulianiti K, Jamurtas A, Kostikas K, Tzatzarakis M, et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol. 2013;25:91–101.

Giroud C, de Cesare M, Berthet A, Varlet V, Concha-Lozano N, Favrat B. E-Cigarettes: A Review of New Trends in Cannabis Use. Int J Environ Res Public Health. 2015;12:9988–10008.

Tan A, Bigman C. E-Cigarette Awareness and Perceived Harmfulness. Am J Prev Med. 2014;47:141–9.

Jamal A, Gentzke A, Hu S, Cullen K, Apelberg B, Homa D, et al. Tobacco Use Among Middle and High School Students — United States, 2011–2016. MMWR. Morb Mortal Wkly Rep. 2017;66:597–603.

Action on Smoking and Health. Use of electronic cigarettes (vapourisers) among adults in Great Britain, 2015. Available at: http://www.ash. org.uk/files/documents/ASH_891.pdf. Accessed on 31 July 2017.

Brown J, West R, Beard E. Smoking Toolkit Study. Trends in electronic cigarette use in England, 2014. Available at: http://www.smokinginengland.info/ latest-statistics/. Accessed on 1 August 2017.

Action on Smoking and Health (ASH), YouGov. Use of electronic cigarettes among children in Great Britain, 2015. Available at: http://ash.org.uk/files/ documents/ASH_959.pdf. Accessed on 9 August 2017.

Withers J. Office for National Statistics. Adult smoking habits in the UK, 2016. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2016. Accessed on 31 July 2017.

Office for National Statistics. E-cigarette use in Great Britain, 2016. Available from: http://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/ecigaretteuseingreatbritain. Accessed on 12th August 2017.

Houezec J. According to a new survey, youth smoking decreased during the last 4 years while e-cig used increased, 2014. Available at: http://www.leparisien.fr/societe/etude-les-ados-moins-accros-au-tabac-16-05-2014-3845399.php. Accessed on 31 July 2017.

Gravely S, Fong G, Cummings K, Yan M, Quah A, Borland R, et al. Awareness, Trial, and Current Use of Electronic Cigarettes in 10 Countries: Findings from the ITC Project. Int J Environ Res Public Health. 2014;11:11691–704.

Lobb B. Vaping: Towards a regulatory framework for e-cigarettes: Report of the standing committee on health, 2015. Available at: http://www.ourcommons.ca/DocumentViewer/en/41-2/HESA/report-9. Accessed on 31 July 2017.

Royal College of Physicians, London. Nicotine without smoke: Tobacco harm reduction, 2016. Available at: https://www.rcplondon.ac.uk/projects/ outputs/nicotine-without-smoke-tobacco-harm-reduction-0. Accessed on 9 August 2017.

U.S. Food & Drug Administration. The Facts on the FDA’s New Tobacco Rule, 2016. Available at: https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm506676.htm. Accessed 31st July 2017.

Huang J, Tauras J, Chaloupka F. The impact of price and tobacco control policies on the demand for electronic nicotine delivery systems. Tob Control. 2014;23 Suppl 3:iii41-7.

Carpenter C, Cook P. Cigarette taxes and youth smoking: new evidence from national, state, and local Youth Risk Behavior Surveys. J. Health Econ. 2008;27:287–99.

Coleman B, Apelberg B, Ambrose B, Green K, Choiniere C, Bunnell R, et al. Association Between Electronic Cigarette Use and Openness to Cigarette Smoking Among US Young Adults. Nicotine Tob. Res. 2015;17:212–8.




How to Cite

Nachiappan, A. C., & Selvavinayagam, T. S. (2017). E-cigarettes: promise or threat?. International Journal Of Community Medicine And Public Health, 4(9), 3059–3067. https://doi.org/10.18203/2394-6040.ijcmph20173710



Review Articles