Clinical Pharmacology of Electronic Nicotine Delivery Systems (ENDS): Implications for Benefits and Risks in the Promotion of the Combusted Tobacco Endgame

Abstract

Electronic nicotine delivery systems (ENDS) such as e‐cigarettes and heated tobacco products are novel battery‐operated devices that deliver nicotine without combustion of tobacco. Because cigarette smoking is sustained by nicotine addiction and the toxic combustion products are mainly responsible for the harmful effects of smoking, ENDS could be used to promote smoking cessation while exposing users to lower levels of toxicants compared with conventional cigarettes. The currently available evidence from clinical and observational studies indicates a potential role of e‐cigarettes as smoking cessation aids, although many continue to use e‐cigarettes long after quitting smoking. Nicotine and toxicant delivery vary considerably by device and depend on the characteristics of the e‐liquid formulation. Because smokers tend to titrate their nicotine intake to maintain their desired pharmacologic effects, device and liquid characteristics need to be considered when using ENDS as an aid to quit smoking. Factors potentially limiting their use are the currently still unknown long‐term safety of these products and concerns regarding widespread use among youth. Implications of clinical pharmacology data on ENDS for the cigarette endgame and regulation by the U.S. Food and Drug administration are discussed.

E-Cigarettes—a review of the evidence—harm versus harm reduction

“… 1 Some of these devices have modifiable cartridges while others have a standard prefilled “pod.” A commercially produced pod contains approximately the same nicotine found in an average pack of combustible tobacco cigarettes; however, nicotine content and effective dose of nicotine per pod can vary widely. 5 Many of these fourth generation devices can deliver nicotine similarly to smoking cigarettes and levels can peak within 5 minutes of inhaling the aerosol. These devices also vary from earlier generations by having the ability to produce higher temperatures with increased power to better simulate smoking and increase delivery of the aerosol.…”

“…6 In 2019, 17% of Canadian adolescents and 12.6% of UK adolescents reported using e-cigarettes, and the latest data from South Korea, from 2017, reported only 2.0% teen use. 5 …”

“…The concentration can be quite high and therefore can cause toxicity. 5 Higher blood levels of nicotine have been associated with vaping as compared to combustible tobacco. There are varying formulations of nicotine which also has an impact on absorption.…”

The Predictive Utility of Valuing the Future for Smoking Cessation: Findings from the ITC 4 Country Surveys

“…Most smokers have a strong emotional attachment to smoking, a conditioned response built up from smoking thousands of cigarettes (i.e., they have a strong disposition to smoke); that is, it has become a habit. The difficulty most smokers experience in trying to quit [ 30 , 31 ] demonstrates that smoking is also sustained by the body’s response to nicotine, a dependence producing drug [ 32 , 33 ]. The combination of habitual factors and the biological dependence makes smoking cessation particularly difficult which means it requires high levels of executive-generated effort by the smoker, if smoking is to be successfully resisted [ 32 , 33 , 34 , 35 ].…”

“…The difficulty most smokers experience in trying to quit [ 30 , 31 ] demonstrates that smoking is also sustained by the body’s response to nicotine, a dependence producing drug [ 32 , 33 ]. The combination of habitual factors and the biological dependence makes smoking cessation particularly difficult which means it requires high levels of executive-generated effort by the smoker, if smoking is to be successfully resisted [ 32 , 33 , 34 , 35 ]. This requires a powerful story where both motivation and persistence are needed to achieve the goal of smoking cessation.…”