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Objective: Globally, indoor and outdoor pollutants are leading risk factors for death and reduced quality of life. Few theories explicitly address environmental health within the nursing discipline with a focus on harmful environmental exposures. The objective here is to expand the National Institutes of Health Symptom Science Model to include the environmental health concepts of environmental endotype (causative pathway) and environmental exposure. Design: Meleis' research to theory strategy for theory refinement was used. Research workshop proceedings, environmental health nursing research expert consensus, panelist research trajectories, and review of the literature were utilized as data sources. Results: Ongoing emphasis on the physical environment as a key determinant of health and theoretical perspectives for including environmental exposures and endotypes in symptom science are presented. Definitions of these concepts, further developed, are provided. Recommendations to strengthen environmental health nursing research and practice through capacity building/infrastructure, methods/outcomes, translational/clinical research, and basic/mechanistic research are included. Conclusion: The revised model deepens theoretical support for clinical actions that include environmental modification, environmental health education, and exposure reduction. This modification will enable a middle-range theory and shared mental model to inspire the prioritization of environmental health in nursing leadership, research, practice, and education. K E Y W O R D S endotype, Environmental Health Science, environmental justice, exposure, nursing theory, Symptom Science Model | 717 CASTNER ET Al.

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Electronic cigarettes (e-cigarettes) are battery-powered devices designed to heat and aerosolize liquids with constituents such as propylene glycol, glycerol as humectants, varied flavors, and in most cases, nicotine (McRobbie et al., 2015). Since coming on the market in the United States and Europe in 2006 (Rahman et al., 2014), e-cigarettes have increased in popularity. Globally, the number of vapers has grown from seven million in 2011 to 41 million in 2018, and is estimated to increase to 55 million by 2021 (Jones, 2019). The United States ranks as the number one market for vape products

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