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Systematic review
Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies
  1. Taghrid Asfar1,2,
  2. Rime Jebai3,
  3. Wei Li4,
  4. Olusanya Joshua Oluwole1,2,
  5. Tarana Ferdous3,
  6. Prem Gautam3,
  7. Michael Schmidt5,
  8. Seth M Noar6,
  9. Eric N Lindblom7,
  10. Thomas Eissenberg8,
  11. Zoran Bursac9,
  12. Donna Vallone10,11,
  13. Wasim Maziak12
  1. 1Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
  2. 2Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
  3. 3Robert Stempel College of Public Health and Social Work, Department of Epidemiology, Florida International University, Miami, FL, USA
  4. 4Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
  5. 5Department of Art, The University of Memphis, Memphis, TN, USA
  6. 6Hussman School of Journalism and Media, University of North Carolina System, Chapel Hill, NC, USA
  7. 7O'Neill Institute for National & Global Health Law, Georgetown University Law Center, Washington, DC, USA
  8. 8Psychology and Institute for Drug/Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA
  9. 9Biostatistics, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA
  10. 10Schroeder Institute, Truth Initiative, Washington, DC, USA
  11. 11Truth Initiative Schroeder Institute, New York University College of Global Public Health, New York, NY, USA
  12. 12Epidemiology, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA
  1. Correspondence to Dr Taghrid Asfar, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA; tasfar{at}med.miami.edu

Abstract

Objectives This umbrella review aims to summarise the evidence about electronic nicotine delivery systems’ (ENDS) risk and safety health profile to inform ENDS health communication strategies.

Data sources and study selection Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4.

Data extraction Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine’s Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive.

Data synthesis We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes.

Conclusions As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided.

PROSPERO registration number CRD42021241630.

  • Electronic nicotine delivery devices
  • Public policy
  • Smoking Caused Disease
  • Advertising and Promotion
  • Human rights

https://doi.org/10.1136/tc-2022-057495

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    Footnotes

    • Contributors TA and WM contributed to the conception and design of the study, supervised data collection, contributed to interpretation of the data and critically revised the manuscript for important intellectual content. RJ, WL, OJO, TF and PG performed the literature review and data collection, and reviewed quality assessment. TA, OJO and ZB performed data cleaning and data meta-analyses. All authors contributed to interpretation of the data and critically revised the manuscript for important intellectual content. This manuscript was written by TA with input from all coauthors who read and approved the final version.

    • Funding Funding for this study was supported by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH) (R01DA051836).

    • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or FDA.

    • Competing interests All authors (except TE) certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. TE is a paid consultant in litigation against the tobacco industry and also the electronic cigarette industry and is named on one patent for a device that measures the puffing behaviour of electronic cigarette users, on another patent application for a smartphone app that determines electronic cigarette device and liquid characteristics, and a third patent application for a smoking cessation intervention. The CSTP is supported by grant number U54DA036105 from the National Institute on Drug Abuse of the National Institutes of Health and the Center for Tobacco Products of the US Food and Drug Administration. The content of this paper is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.