- Scientists think they know why vaping is killing people
- RELATED: A Smoke-Free Generation Is Within Reach — And Here's How
- RELATED: Are Vaporizers Really Helping People Kick Smoking?
- Vaping nearly killed me, says British teenager
- What happened?
- How is Ewan now?
- Is vaping to blame?
- How common is this?
- Is vaping dangerous?
- Is Ewan's case similar to those in the US?
- What do experts says?
- Clearing up some myths around e-cigarettes
- MYTH 1 – E-cigarettes give you ‘popcorn lung’
- MYTH 2 – E-cigarettes aren’t regulated and we don’t know what’s in them
- MYTH 3 – E-cigarettes must be harmful as they contain nicotine
- MYTH 4 – Exposure to e-cigarette vapour is harmful to bystanders
- MYTH 5 – E-cigarettes will lead young people into smoking
- MYTH 6 – E-cigarettes are being used as a Trojan horse – so the tobacco industry can keep people smoking
- Myth 7 – E-cigarettes don't help you quit smoking
- Quick Facts on the Risks of E-cigarettes for Young People
Scientists think they know why vaping is killing people
The vaping epidemic is a PSA come to life. A recent outbreak of vaping-related deaths and illnesses has affected people from across 46 states. More than 800 people fell ill, and at least 17 people died from vaping.
In Illinois and Wisconsin, 87% of the people who got sick said they used THC, and 71% of people also said they used products that contained nicotine. Symptoms of the illness included coughing, chest pains, shortness of breath, nausea, and fatigue.
We finally might now why.
Researchers from the Mayo Clinic believe toxic chemical fumes, not the actual chemicals in the vape liquid, might be the culprit. “It seems to be some kind of direct chemical injury, similar to what one might see with exposures to toxic chemical fumes, poisonous gases and toxic agents,” Dr. Brandon Larsen, a surgical pathologist at the Mayo Clinic in Arizona, said in release.
Initially, researchers thought lung damage was caused by accumulation of vape oils. However, when they looked at samples of lung tissues from 17 people who had vaped, they couldn't find evidence of lipoid pneumonia, a rare form of pneumonia caused by inhaling oils.
Two of the patients studied had died from vaping, and 70% of the patients studied had used marijuana or cannabis oils. ” what we have seen in our study, we suspect that most cases involve chemical contaminants, toxic byproducts or other noxious agents within vape liquids,” Larsen said.
Scientists have confirmed what common sense should have already told us – inhaling toxic chemicals is bad for you.
RELATED: A Smoke-Free Generation Is Within Reach — And Here's How
This is the first formal study of lung tissue from people who have fallen ill after vaping. Vaping is still a relatively new alternative to smoking. The first commercially successful e-cigarette was developed in 2003, and they were introduced into the U.S. in 2006. We're still learning about the consequences of vaping.
Just because researchers have narrowed down what might be causing the illnesses doesn't mean we're the water just yet. Researchers still have to discover what chemicals are causing the illnesses and deaths.
For now, the American Lung Association warns against vaping as it can cause irreversible lung damage, and Dr. Larson concurs.
“Everyone should recognize that vaping is not without potential risks, including life-threatening risks, and I think our research supports that,” he said.
RELATED: Are Vaporizers Really Helping People Kick Smoking?
The FDA is considering banning non-tobacco vape liquids altogether, and Michigan has already banned sales of e-cigarettes. San Francisco and Boulder, Colorado have similar bans as well.
This recent epidemic is a reminder that no form of smoking, electronic or otherwise, is truly safe. If you're trying to kick the habit, it might just be better to cut the habit altogether, rather than replace it with alternative forms of smoking.
Vaping nearly killed me, says British teenager
By James Gallagher Health and science correspondent
Media playback is unsupported on your device
Media captionEwan Fisher: 'Everything just got worse and worse… I nearly lost my life'
A teenage boy nearly died after vaping caused a catastrophic reaction in his lungs, doctors in Nottingham say.
Ewan Fisher was connected to an artificial lung to keep him alive after his own lungs failed and he could not breathe.
Ewan told BBC News e-cigarettes had “basically ruined me” and urged other young people not to vape.
His doctors say vaping is “not safe”, although health bodies in the UK say it is 95% safer than tobacco.
Ewan started vaping in early 2017. He was 16 at the time and wanted to quit smoking to improve his boxing.
Despite being under age, he said, “it was easy” to buy either cigarettes or e-cigarettes.
In May that year, Ewan was finding it harder and harder to breathe.
His mother took Ewan to accident and emergency on the night before his GCSE exams, because he was coughing and choking in his sleep.
His lungs were failing and he very quickly ended up on life-support in intensive care in Queen's Medical Centre in Nottingham.
“I thought I was going to die,” Ewan told BBC News.
Ewan was getting worse. Even ventilation could not get enough oxygen into his body and his life was in the balance.
Image copyright Ewan Fisher Image caption Ewan was attached to an ECMO machine to keep him alive
He was taken to Leicester and attached to an artificial lung or ECMO (extra-corporeal membrane oxygenation) machine.
“This machine saved my life,” he said.
Large tubes took blood Ewan, removed the carbon dioxide, added oxygen and pumped the blood back into his body.
“He had very serious respiratory failure, he had to go to ECMO and that is a very big deal,” Dr Jayesh Bhatt, a consultant at Nottingham University Hospitals, told BBC News.
“He got as ill as anyone can get.”
The case – from May 2017 – has just come to light in the journal Archives of Disease in Childhood.
How is Ewan now?
Ewan, who is 19 on Tuesday, had a long recovery. It was six months before he was properly up and on his feet again.
“I'm still not back to normal, I'd say 75-80%, it's in the last six months that I'm feeling a bit stronger in myself,” he said.
“Vaping has basically ruined me, I try to tell everyone and they think I'm being stupid, I tell my mates and they don't listen.
“They still do it… but they've seen what I've been through.
“Is it worth risking your life for smoking e-cigs?
“I don't want you to end up me and I don't want you to be dead, I wouldn't wish [that] on anyone.”
Ewan also fears being around other vapers – everywhere from the pub to High Street – could damage his lungs again.
Is vaping to blame?
His doctors say the answer is yes.
Ewan developed a condition called hypersensitivity pneumonitis – something he was breathing in was setting off his immune system, with catastrophic consequences.
“You get an over-exuberant inflammatory response and the lungs pay a price and develop respiratory failure,” Dr Bhatt said.
One of the most common forms of hypersensitivity pneumonitis is “bird fancier's lung”, which is caused by particles from feathers or bird droppings.
When scientists tested the two e-cigarette liquids Ewan had been using, they found one of them was triggering an immune reaction.
Dr Bhatt said: “The real learning point is vaping is not safe, especially for young people, they should never go near it.
“We consider e-cigarettes as 'much safer than tobacco' at our peril.”
Image copyright Getty Images
How common is this?
There are 3.6 million people vaping in the UK and reactions this are rare.
However, doctors have told BBC News Ewan's case is not an isolated incident.
“As vaping becomes more popular, we are beginning to see more cases,” Dr Hemant Kulkarni, a consultant in paediatric respiratory medicine at Sheffield Children's NHS Foundation Trust, said.
He told BBC News: “Some of the cases my colleagues and I have seen are teenagers presenting with severe lung injury and some of these have been life-threatening.
“However, in the cases I've been involved in, patients are now regaining normal lung function.”
Dr Kulkarni is “surprised” e-cigarettes are advertised in the UK, given the severe reaction they can cause in children and a lack of scientific studies on their safety.
Is vaping dangerous?
Smoking is pretty much the worst thing you can do for your health.
E-cigarettes are promoted in the UK as a way to quit because they let people inhale nicotine in vapour rather than breathing in smoke.
Ewan's reaction was extreme, but what about the rest of us who would not end up with hypersensitivity pneumonitis?
Public Health England says vaping is 95% safer than smoking but is not without risks.
Rosanna O' Connor, the body's director of drugs, alcohol and tobacco, said: “Smoking kills half of lifelong smokers and accounts for almost 220 deaths in England every day.
“Our advice remains that while not completely risk free, UK regulated e-cigarettes carry a fraction of the risk of smoked tobacco.”
But there are arguments about how safe vaping really is.
The World Health Organization says e-cigarettes are “undoubtedly harmful and should therefore be subject to regulation”.
It also raises concerns vaping is being aggressively marketed at young people – particularly through the use of flavourings – and risked re-normalising smoking.
Is Ewan's case similar to those in the US?
The deaths of 39 people in the US have been connected to vaping and have prompted worldwide concern about its safety.
There have been 2,051 cases of e-cigarette, or vaping, product use associated lung injury (called EVALI) in the outbreak.
Most of those cases, but not all, have been linked to vaping THC, the psychoactive ingredient in cannabis.
Ewan was using standard e-cigarettes bought from a shop.
What do experts says?
Dr Nick Hopkinson, medical director of the British Lung Foundation, said: “If people switch completely from smoking to vaping, they will substantially reduce their health risk as e-cigarettes do not contain tobacco and any harmful components are present at a much lower level.
“People who do switch should try to quit vaping in the long term too but not at the expense of relapsing to smoking – and non-smokers should not take up vaping.”
Prof John Britton, the director of the UK Centre for Tobacco and Alcohol Studies, at the University of Nottingham, said: “This is worrying, and the risk needs to be acknowledged, but in absolute terms it is extremely small and, crucially, far smaller than that of smoking.
“The advice remains the same: if you smoke, switch to vaping; if you don't smoke, don't vape.”
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Clearing up some myths around e-cigarettes
Updated on 27 February 2019.
No doubt you will have seen some of the stories in the media recently following the publication of PHE’s latest update of the evidence on e-cigarettes. E-cigarettes do seem to be a bit Marmite, courting controversy among the public and media a.
Not surprisingly, there are lots of inaccuracies and misconceptions about e-cigarettes and vaping. This blog looks at some of the most common myths and provides the facts.
Our latest independent e-cigarette review, authored by leading academics in the tobacco control field, focuses on the up-to-date facts about vaping among adults and young people in England.
Despite the sometimes confused, and confusing, media reporting around the safety of e-cigarettes, there is growing consensus around the evidence. While not without some risk, when compared to smoking e-cigarettes are far less harmful.
This view is supported by a number of key bodies, including Cancer Research UK, Action on Smoking and Health, the Royal College of Physicians, the British Medical Association and recently, a major US science body, the National Academies of Sciences, Engineering, and Medicine.
For a fuller picture of the review’s findings please see our blog: E-cigarette evidence update – patterns and use in adults and young people.
MYTH 1 – E-cigarettes give you ‘popcorn lung’
One of the most commonly held concerns is that e-cigarettes might cause ‘popcorn lung’. This came about because some flavourings used in e-liquids to provide a buttery flavour contain the chemical diacetyl, which at very high levels of exposure has been associated with the serious lung disease bronchiolitis obliterans.
The condition gained its popular name because it was initially observed among workers in a popcorn factory.
However, diacetyl is banned as an ingredient from e-cigarettes and e-liquids in the UK. It had been detected in some e-liquid flavourings in the past, but at levels hundreds of times lower than in cigarette smoke. Even at these levels, smoking is not a major risk factor for this rare disease.
MYTH 2 – E-cigarettes aren’t regulated and we don’t know what’s in them
The UK has some of the strictest regulation for e-cigarettes in the world. Under the Tobacco and Related Products Regulations 2016, e-cigarette products are subject to minimum standards of quality and safety, as well as packaging and labelling requirements to provide consumers with the information they need to make informed choices.
All products must be notified by manufacturers to the UK Medicines and Healthcare products Regulatory Agency (MHRA), with detailed information including the listing of all ingredients.
MYTH 3 – E-cigarettes must be harmful as they contain nicotine
Four 10 smokers and ex-smokers wrongly think nicotine causes most of the tobacco smoking-related cancer, when evidence shows nicotine actually carries minimal risk of harm to health. Although nicotine is the reason people become addicted to smoking, it is the thousands of other chemicals contained in cigarette smoke that causes almost all of the harm.
E-cigarette vapour does not contain tar or carbon monoxide, two of the most harmful elements in tobacco smoke. It does contain some chemicals also found in tobacco smoke, but at much lower levels.
MYTH 4 – Exposure to e-cigarette vapour is harmful to bystanders
The evidence is clear that exposure to second hand smoke is harmful, which is why the UK has laws prohibiting smoking in enclosed public places and workplaces. These laws do not cover vaping and organisations are free to make their own policies on the use of e-cigarettes on their premises.
E-cigarette liquid is typically composed of nicotine, propylene glycol and/or glycerine, and flavourings. Un cigarettes, there is no side-stream vapour emitted by an e-cigarette into the atmosphere, just the exhaled aerosol.
PHE’s 2018 evidence review found that to date, there have been no identified health risks of passive vaping to the health of bystanders.
People with asthma and other respiratory conditions can be sensitive to a range of environmental irritants, as well as pollen and cold air and PHE advises organisations to take this into account and to make adjustments where appropriate, when making their own policies on the use of e-cigarettes..
MYTH 5 – E-cigarettes will lead young people into smoking
Our latest report found no evidence so far to support the concern that e-cigarettes are a route into smoking among young people. UK surveys show that young people are experimenting with e-cigarettes, but regular use is rare and confined almost entirely to those who already smoke. Meanwhile, smoking rates among young people in the UK continue to decline.
There is also no evidence to support the assertion that vaping is “normalising smoking”. In the years when adult and youth vaping in the UK were increasing, the numbers of young people believing that it was ‘not ok’ to smoke was accelerating. Of course, PHE will continue to monitor the trends in e-cigarette use alongside those in smoking.
MYTH 6 – E-cigarettes are being used as a Trojan horse – so the tobacco industry can keep people smoking
There is currently no evidence to suggest that e-cigarettes are encouraging people to continue smoking – the picture in the UK suggests the opposite. The proportion of e-cigarette users who are ex-smokers has been increasing over recent years.
Of the 3.2 million adult e-cigarette users in the UK, more than half have completely stopped smoking. A further 770,000 have given up both smoking and vaping. At the same time, quit success rates have been improving and we’re seeing an accelerated drop in smoking rates, currently at a record low of 14.9%in England.
Myth 7 – E-cigarettes don't help you quit smoking
Separate from our review, a major UK NIHR funded clinical trial was published in February 2019.
Involving nearly 900 participants, it found that in Local Stop Smoking Services, a standard e-cigarette was twice as effective at helping smokers to quit compared with the quitters’ choice of combination nicotine replacement therapy (NRT).
Both groups were provided with behavioural support and those in the e-cigarette group had significantly faster reductions in cough and phlegm.
In summary, e-cigarettes and tobacco cigarettes are not the same and shouldn’t be treated as such. It’s important that England’s seven million smokers are aware of the differences and have accurate information to inform their health decisions. E-cigarettes aren’t completely risk free but carry a fraction of the risk of smoking and are helping thousands of smokers to quit and stay smokefree.
Quick Facts on the Risks of E-cigarettes for Young People
- The use of e-cigarettes is unsafe for kids, teens, and young adults.
- Most e-cigarettes contain nicotine. Nicotine is highly addictive and can harm adolescent brain development, which continues into the early to mid-20s.
- E-cigarettes can contain other harmful substances besides nicotine.
- Young people who use e-cigarettes may be more ly to smoke cigarettes in the future.
The use of e-cigarettes is unsafe for kids, teens, and young adults.
- E-cigarettes are electronic devices that heat a liquid and produce an aerosol, or mix of small particles in the air.
- E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid.
- Some e-cigarettes look regular cigarettes, cigars, or pipes. Some look USB flash drives, pens, and other everyday items. Larger devices such as tank systems, or “mods,” do not look other tobacco products.
- E-cigarettes are known by many different names. They are sometimes called “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems (ENDS).”
- Using an e-cigarette is sometimes called “vaping” or “JUULing.”
Some e-cigarettes look regular cigarettes, cigars, or pipes.
Some look USB flash drives, pens, and other everyday items.
- E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other chemicals that help to make the aerosol.
- The liquid used in e-cigarettes often contains nicotine and flavorings. This liquid is sometimes called “e-juice,” “e-liquid,” “vape juice,” or “vape liquid.”
- Users inhale e-cigarette aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales it into the air.
- E-cigarette devices can be used to deliver marijuana and other drugs.
News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.
- JUUL is a brand of e-cigarette that is shaped a USB flash drive. other e-cigarettes, JUUL is a battery-powered device that heats a nicotine-containing liquid to produce an aerosol that is inhaled.
- All JUUL e-cigarettes have a high level of nicotine. According to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes.2
- JUUL is one of a few e-cigarettes that use nicotine salts, which allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes.
- News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.
- Approximately two-thirds of JUUL users aged 15 – 24 do not know that JUUL always contains nicotine.
- Although JUUL is currently the top-selling e-cigarette brand in the United States, other companies sell e-cigarettes that look USB flash drives. Examples include the MarkTen Elite, a nicotine delivery device, and the PAX Era, a marijuana delivery device that looks JUUL.
- Additional information about USB-shaped e-cigarettes and actions that parents, educators, and health care providers can take to protect kids is available at CDC’s Infographicpdf icon [PDF – 1.2MB]
- Most e-cigarettes contain nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products.
- A recent CDC study found that 99% of the e-cigarettes sold in assessed venues in the United States contained nicotine.
- Some e-cigarette labels do not disclose that they contain nicotine, and some e-cigarettes marketed as containing 0% nicotine have been found to contain nicotine.
- Nicotine can harm the developing adolescent brain.1 The brain keeps developing until about age 25.
- Using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood, and impulse control.1
- Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells. Young people’s brains build synapses faster than adult brains. Nicotine changes the way these synapses are formed.
- Using nicotine in adolescence may also increase risk for future addiction to other drugs.1
- Scientists are still learning about the long-term health effects of e-cigarettes.
- Some of the ingredients in e-cigarette aerosol could also be harmful to the lungs in the long-term. For example, some e-cigarette flavorings may be safe to eat but not to inhale because the gut can process more substances than the lungs.1
- Defective e-cigarette batteries have caused some fires and explosions, a few of which have resulted in serious injuries.
- Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes. Nationally, approximately 50% of calls to poison control centers for e-cigarettes are for kids 5 years of age or younger.
- E-cigarette aerosol is NOT harmless “water vapor.”
- The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances, including:
- Ultrafine particles that can be inhaled deep into the lungs
- Flavorings such as diacetyl, a chemical linked to a serious lung disease
- Volatile organic compounds
- Cancer-causing chemicals
- Heavy metals such as nickel, tin, and lead1
- The aerosol that users inhale and exhale from e-cigarettes can expose both themselves and bystanders to harmful substances.
- It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.3
- Many e-cigarettes come in fruit, candy, and other kid-friendly flavors, such as mango, fruit and crème.
- A majority of youth e-cigarette users report using flavored varieties, most youth e-cigarette users first start using e-cigarettes with a flavored variety, and flavors are the primary reason youth report using e-cigarettes.
- E-cigarettes are also advertised using the same themes and tactics that have been shown to increase youth initiation of other tobacco products, including cigarettes. In 2016, about 8 in 10 middle school and high school students—more than 20 million youth—said they had seen e-cigarette advertising.
- Widespread advertising for these products, including via media for which advertising for conventional tobacco products is prohibited (e.g., TV), and the lower costs of some of these products relative to conventional cigarettes has contributed to the increase in e-cigarette use among youth.
- Many youth also report using e-cigarettes because they are curious about these new products, and because they believe these products to be less harmful than conventional cigarettes.
- Many young people who use e-cigarettes also smoke cigarettes.1 There is some evidence that young people who use e-cigarettes may be more ly to smoke cigarettes in the future.
- Specifically, a 2018 National Academy of Medicine report found that there was some evidence that e-cigarette use increases the frequency and amount of cigarette smoking in the future.4
- E-cigarettes also can be used to deliver other drugs, including marijuana; in 2016, approximately one-third of U.S. middle and high school students who have ever used an e-cigarette reported using marijuana in the device.
- But e-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking.
- E-cigarettes expose users to fewer harmful chemicals than burned cigarettes.1 But burned cigarettes are extraordinarily dangerous, killing half of all people who smoke long-term.
- The use of any tobacco product, including e-cigarettes, is unsafe for young people.
- Yes. In August 2016, the regulatory authority of the FDA was extended to cover e-cigarettes through the agency’s “deeming rule.”
- Through authority granted by the Family Smoking Prevention and Tobacco Control Act (FSPTCA), FDA has authority to develop regulations that address the manufacturing, marketing, and sale of e-cigarettes.
- However, the FSPTCA does not prevent states and communities from adopting many strategies related to e-cigarettes. There are also many strategies that FDA does not have authority to implement and that states can do, such as including e-cigarettes in smoke-free policies, pricing strategies, and increasing the age of sale for tobacco products to 21.
- Yes. In 2018, the FDA expanded its successful youth tobacco prevention campaignexternal icon, “The Real Cost,” to reach the more than 10 million youth aged 12–17 who have used e-cigarettes or are open to trying them. The campaign educates youth about the potential risks of using e-cigarettes.
- The “Real Cost” reaches teens where they spend most of their time: in school and online. The campaign is also placing e-cigarette prevention materials in high schools across the nation, both in school bathrooms and on educational digital platforms accessed by students during the school day.
- The Truth Initiative® launched the “Safer ≠ Safe” campaign in 2018, focusing on correcting youth misperceptions and providing accurate information about e-cigarettes and youth. The campaign is being promoted on digital and social media, including the Safer ≠ Safe websiteexternal icon, which features videos, articles and interactive activities for youth.
- Heated tobacco products (HTPs) IQOS and Eclipse, sometimes marketed as “heat-not-burn” technology, represent a diverse class of products that heat the tobacco leaf to produce an inhaled aerosol. They are different from e-cigarettes, which heat a liquid that can contain nicotine derived from tobacco.
- HTPs are available in at least 40 countries and have several have been authorized for sale in the United States by the FDA. In 2018, few U.S. adults (2.4% of all surveyed, including 6.7% of current smokers surveyed) had ever used HTPs. Youth use of HTPs is unknown, but monitoring is underway.
- Scientists are still learning about the short-term and long-term health effects of HTPs, but the available science shows they contain harmful and potentially harmful ingredients. Youth use of any tobacco products, including heated products, is unsafe.
- It is important that we continue to modernize proven tobacco prevention and control strategies to include newer products entering the market such as HTPs.
Talk to your child or teen about why e-cigarettes are harmful for them. It’s never too late.
- Set a good example by being tobacco-free and ensure that your kid is not exposed to the secondhand emissions from any tobacco products, including e-cigarettes.
- If you use tobacco, it’s never too late to quit. For free help, visit smokefree.govexternal icon or call 1-800-QUIT-NOW.
- Talk to your child or teen about why e-cigarettes are harmful for them. It’s never too late.
- Get the Talk With Your Teen About E-cigarettespdf iconexternal icon [PDF – 5.2MB] tip sheet for parents. Start the conversation early with children about why e-cigarettes are harmful for them.
- Let your child know that you want them to stay away from all tobacco products, including e-cigarettes, because they are not safe for them. Seek help and get involved.
- Set up an appointment with your child’s health care provider so that they can hear from a medical professional about the health risks of tobacco products, including e-cigarettes.
- Speak with your child’s teacher and school administrator about enforcement of tobacco-free school grounds policies and tobacco prevention curriculum.
- Encourage your child to learn the facts and get tips for quitting tobacco products at Teen.smokefree.govexternal icon.
- US Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon Generalpdf icon [PDF – 8.47MB]. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. Accessed July 27, 2018.
- Willett JG, Bennett M, Hair EC, et al Recognition, use and perceptions of JUUL among youth and young adults. Tobacco Control Published Online First: 18 April 2018. doi: 10.1136/tobaccocontrol-2018-054273
- Goniewicz ML, Gupta R, Lee YH, et al. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the United States, Korea, and Poland. Int J Drug Policy. 2015;26(6):583–588.
- National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettesexternal icon. Washington, DC: The National Academies Press.