Electronic Nicotine Delivery

Systems (ENDS)
Karina DiLuzio, BS, CTTS, NBC-HWC and
Julee Moorlag, RCP, CTTS
2017
 Agenda
• To be able to educate patients on the dangers
and unknowns associated with electronic
cigarettes
• To have knowledge of Allina’s policy on using the
electronic cigarette on campus grounds

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 ENDS – Electronic Nicotine
Delivery Systems
• vaporizers
• vape pens
• hookah pens
• electronic cigarettes (E-Cigarettes)
• e-pipes
• JUUL
• Suorin Air
• Suorin Drop
• Several others
 ENDS: Electronic Nicotine
Delivery System
• Also called the “e-cigarette”, the “water
cigarette”, “water vapor” cigarette.
• Use of this product is called “vaping” or “juuling”.
• Inside is a battery and metal coil. There often is
a light at the end of the cigarette to simulate the
“glow”.
• Originally marketed as a means to continue
smoking without using cigarettes.

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 Trinketsandtrash.org
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 The Components

FDA.GOV
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 Method of Use
• There is a place for a cartridge of nicotine or
liquid nicotine to be inserted.
• Person inhales, which activates battery. The
metal coil heats, and the nicotine and other
ingredients, including flavorings, are pulled past
the coil, which “vaporizes” them into a type of
steam. This steam is inhaled as well as
released at the end of the product to simulate
smoke.

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According to FDA testing done
in 2009, the e-cig contains:
• At least two known carcinogens
- Nitrosamines
- Propylene Glycol (found in non-toxic antifreeze and is
a food additive. Also in asthma inhalers and
nebulizers) When HEATED in the e-cig, this becomes
a carcinogen!
• Currently there are 26 known chemicals found in
ENDS, identified as “hazardous or toxic” by the
FDA.
• The nicotine used in e-cigarettes is not filtered or
purified as it is in NRT. This means it contains
chemicals inherent in the tobacco leaf, which are
toxic.

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• Varying dosages of nicotine despite labeling:
- Dosages vary from cartridge to cartridge, despite
declared amount. It is nearly impossible to dose
NRT accurately with e-cig use (with just the
product labeling and pt’s description of use).
- E-cigs are constantly evolving. First generation
e-cigs didn’t deliver nicotine very well, so users
changed the way in which they smoked, holding
their breath or inhaling deeper to get more
nicotine. New generation e-cigs deliver more
nicotine but still not like cigarettes.

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 Varying dosages, cont’d
• Some e-cigs are marked zero nicotine, which is not
always true. However, because of the other
chemicals and flavorings in the e-cig, even the ones
without nicotine pose a health concern to users.

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 Known and Suspected Health
Effects
• Several research studies are starting to show
increased cardiovascular and respiratory health
problems associated with use of the e-cig.
• Can lead to an illness known as “Popcorn Lung”,
which happens when diacetyl (a chemical found
in flavoring) is inhaled. This is found in the vast
majority of e-cigs, when recently tested by
Harvard1.

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 Known and Suspected Heath
Effects (continued)
• The metals in the coils can break off into
“whiskers” when heated, and are then inhaled.
• The vapor which escapes from the atomizer is
vaporized chemicals, which is a secondhand
“vape”. It also clings to surfaces and becomes
thirdhand “vape”. Both are health concerns for
those around someone who is vaping.

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 Secondary Health Effects
• ENDS are being increasingly connected with
explosions
• There have been increasing fatalities and
illnesses from nicotine overdoses in children,
often due to easily accessible ENDS
packaging/containment.
• Studies have shown that “vapers” are more likely
to become “smokers”.

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 Idaho man loses 7 teeth after e-cig explodes in face-
Q13 Fox News/ Jan 2017
“I’ve lost at least 7 teeth, 2nd degree burns to face and neck and have been pulling
chunks of plastic, teeth and foreign objects from mouth, throat and lips,”
-Andrew Hall from Facebook post

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JUUL
 JUUL
• JUUL, a product the resembles a flash drive,
dominated the ENDS market in 2017... it was the
most popular selling ENDS product.
• 1 JUUL pod contains a concentrated combination of
nicotine salts and organic acids found in tobacco
leaves, in addition propylene glycol and glycerin. Per
JUUL, this blend more closely resembles the
experience of smoking a cigarette. The company
who manufactures the JUUL received a patent for its
nicotine-salt formulation, which increases the appeal
with a smooth delivery.
• The traditional ENDS products delivers a free based
nicotine which is considered more harsh.
• 1 Juul pod delivers approx. the same amount of
nicotine that smoking 1 ppd does, which occurs
over a series of approx. 200 puffs.
• An average traditional cigarette contains a
significant amount of nicotine, however, about 1
mg of nicotine is absorbed after smoking 1
cigarette.
• The majority of adult smokers that I have worked
with at the hospital have said it’s easier to vape
1 JUUL pod than it is to “burn” through a pack of
cigarettes.
 Now What?
• Although we are discovering more every day, there is much we do
not know about e-cigarettes at this time. Further studies are needed,
especially on long term health affects.
• The U.S. Preventive Services Task Force has rated ENDS an “I” for
“current data is insufficient to recommend them as a smoking
cessation aid”.
• Public Health England has recommended them as a smoking
cessation aid if the person has tried other methods without success.
• The 2018 “Public Health Consequences of E-Cigarettes” by the
National Academies of Science, Engineering, Medicine (NASEM)
was released, confirming that using ENDS products is harmful and
greatly increases tobacco addiction among adolescents.

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 Legalities
• This product is not FDA approved as a smoking
cessation aid. In 2016 a law was made for the FDA
to begin regulating them, however this regulation is
happening very slowly, if at all.
• Companies who mix their own “juice” will be
required to start submitting ingredient lists with a
goal to be done by 2022.
• Very recent: FDA is beginning to take action against
marketing ENDS to youth. (because of the recent
public health report)
• Newest MN legislature requires ENDS be child
proof.

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 Our Stance?
• We know that ENDS contain harmful known and
unknown quantities.
• ENDS have not been approved by the FDA as a
cessation device because empiric evidence has
not proven efficacy over placebo.
• Staff with AllinaHealth will not recommend them
as a cessation or withdrawal aid.
• Staff will encourage patients to consider safer
options.

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 Allina Health Policy
• They are not allowed on Allina property in the
same way that tobacco is not allowed.
• Patients are not allowed to use them while
admitted. For patients going through nicotine
withdrawal, nicotine replacement therapy must
be given through appropriate FDA approved
measures.

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 NRT in ENDS users
• Because it is so difficult to predict how much
nicotine someone is getting from using these
products, Mayo’s Nicotine Dependence Center
recommends starting at 21mg patch and a short
acting NRT prn. If the patient is using the short
acting NRT frequently, go up on the patch. If the
patient feels nauseated or jittery, go down on the
patch. Zyban and Chantix can also be used.

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 Link to Allina’s Tobacco Policy
• http://akn.allina.com/content1/groups/patient-
care/@akn-
qst/documents/policies_procedures/sys-admin-
olt-001.pdf

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 Resources
• 1) American Lung Association:
http://www.lung.org/about-
us/blog/2016/07/popcorn-lung-risk-ecigs.html
• www.FDA.gov
• Mayo Clinic Tobacco Treatment Specialist
Certification program

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