Electronic Nicotine Delivery Systems (ENDS)

Tobacco is one of the world’s major preventable causes of premature death, leading to more than 8 million deaths each year. 
The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) introduced the MPOWER measures in 2007 for tobacco control at the global, regional and country level. MPOWER is a technical package of six measures- monitoring tobacco use and preventive measures; protecting people from tobacco smoke; offering help to quit; warning about the dangers of tobacco; enforcing bans on advertising, promotion and sponsorship; and raising taxes on tobacco. Now, 75% of all countries (consisting of more than 5.3 billion people) have at least one best-practice tobacco control measure (MPOWER measure) in place to protect their people. 
The increase in global coverage of mpower measures since its introduction has helped reduce the global rate of tobacco smoking from 22.7% to 17.5% (in 2019). In India, 8.5% of surveyed students reported being current tobacco users in the Global youth tobacco survey-4 (GYTS-4) conducted in 2019 compared to 14.6 % in GYTS-3 done in 2009.
Newer and emerging nicotine and tobacco products like electronic nicotine delivery systems (ENDS) and heated tobacco products have created a new threat to tobacco control globally. During the unprecedented COVID -19 pandemic, it has become more crucial to protect people from the harmful effects of emerging nicotine and new tobacco products. 
The WHO report on the global tobacco epidemic 2021: addressing new and emerging products has shown that many countries are making progress in the fight against tobacco use. But the proliferation of newer and emerging nicotine (electronic delivery systems) and tobacco products [Heated tobacco products (HTPs)* and Heat-not-burn (HNB) products] is hampering the tobacco control efforts. 
Electronic delivery systems (EDS)
Electronic delivery systems (EDS) are products that use an electrically powered coil to heat and turn a liquid into the aerosols that are inhaled by the users. A portion of the aerosol and gases inhaled into the ENDS user’s lung is exhaled and may cause harm to non-users coming in the proximity. The use of ENDS is rising among never-tobacco smokers and former or current tobacco smokers. 
Electronic delivery systems are of two types:
•Electronic nicotine delivery systems (ENDS) 
•Electronic non-nicotine delivery systems (ENNDS): 
ENDs and ENNDS do not contain tobacco and may or may not contain nicotine. Both are similar, though the e-liquids used in ENNDS are labelled as nicotine-free. In actual situations, many e-liquids marked as “zero-nicotine” contain nicotine when tested. Hence it is difficult to distinguish between ENDS and ENNDS. 
The generation and composition of aerosols during ENDS are responsible for their toxicity and depend on the following factors:
•e-liquid composition, 
•materials used in manufacturing the device, 
•electrical power used to heat the e-liquid, 
•puffing topography or inhaling characteristics of the user while using EN&NNDS.
E-liquid contains a carrier liquid that makes 80–90% of the volume of the e-liquid, some water (about 10–20% of e-liquid), nicotine and flavour. Propylene glycol and glycerol are main carriers used in e-liquids. These undergo partial decomposition in contact with the atomizer heating coil and form several toxicants. Nicotine- a highly addictive substance present in e-liquids may adversely affect fetal and adolescent brain development. The nicotine content of ENDS can range from 0 mg/ml to over 66 mg/ml or more (at least twice the nicotine content of a standard cigarette). Certain flavourings used in e-liquids to attract users are also source of public health concern. 
Heating elements or coils in ENDS& NNDS are usually made of resistance wires of various metals, such as nickel, or metal alloys, including nichrome (chrome and nickel). For heating, the e-liquid, an electrical current from a battery is run through the coil when the EN&NNDS is activated. Under normal operation conditions, the e-liquid reaches a temperature of between 100–350 °C. The amount of nicotine present in the aerosol also depends on the temperature of the solution.  
The inhaling behaviour of users depends on the following variables: puff volume, depth of inhalation, rate of puffing, and intensity of puffing. These variables determine the amount of aerosol inhaled and how deep they reach into the respiratory system.  
The most common ENDS are electronic cigarettes, also known as e-cigarettes, vapes or vape pens. Other categories of ENDS include e-hookahs, e-pipes and e-cigars. Some products resemble their conventional tobacco counterparts; others are shaped like pens, USB memory sticks, or basic cylinders. Many ENDS can be customizable by the user after the sale.
Some types of ENDS help some smokers quit under certain circumstances, but the evidence is insufficient to suggest the use of any type of EN& NNDS as a cessation aid for all smokers. 
Health effects of ENDS: 
There is clear evidence that both types of EDS products are not safe for human use and are harmful to human health.
E-cigarette emissions typically contain nicotine and other toxic substances. These are harmful to both users and non-users exposed to the aerosols. Some products claiming to be nicotine-free have been found to contain nicotine. 
Children and adolescents that use ENDS are more than twice as likely to use conventional cigarettes later in life.
Nicotine exposure to children and adolescents can have long-lasting, damaging effects on their brain development. There is a risk of nicotine addiction as nicotine is highly addictive.
ENDS use increases the risk of heart disease and lung disorders.
ENDS also cause significant risks to pregnant women who are either using the device or exposed to the passive (second-hand) ENDS aerosol. 
Unintentional exposure of children to ENDS liquid including inhalations, eye and skin exposures, and ingestions can produce adverse health effects.
The batteries used in ENDS may cause injuries in the form of burns through fires and explosions. 
There is growing evidence that ENDS could be associated with lung injuries. In recent times e-cigarette and vaping have been linked to an outbreak of lung injury in the USA.
Heated tobacco products (HTPs) and Heat-not-burn (HNB) products: 
These are tobacco products that produce aerosols containing nicotine and other chemicals, which are inhaled by the users, through the mouth. Battery-powered heating systems heat tobacco up to 350°C (temperature lower than 600°C as in conventional cigarettes). The heating system can be an external heat source, or a heated sealed chamber to aerosolize nicotine directly from tobacco leaf. 
All forms of tobacco use are harmful, including HTPs and HNB tobacco products. We must remain vigilant to the challenges posed by new products such as electronic nicotine delivery systems and heated tobacco products. 
WHO  recommendes the regulation of ENDS use globally. In India, the Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) Act was passed in 2019 to protect the people from harmful effects of ENDS. 
The National Tobacco Control Programme (NTCP): 
The Government of India launched the programme in 2007. The programme is being implemented in all 36 States/Union territories of the country.
To know more about NTCP- Click here
•https://www.who.int/publications/i/item/9789240032095 (page 98)
•White Paper on Electronic Nicotine Delivery System accessed from https://ntcp.nhp.gov.in/assets/document/White_Paper_by_Indian_Council_of_Medical_Research.pdf

  • PUBLISHED DATE : Oct 04, 2021
  • LAST UPDATED ON : Oct 04, 2021


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The content on this page has been supervised by the Nodal Officer, Project Director and Assistant Director (Medical) of Centre for Health Informatics. Relevant references are cited on each page.