E-Cigarettes Primer

E-cigarettes Primer: What HCPs and 11 January 2021 – 10 January 2022
Pharmacists Should Know
Program Information
E-cigarettes Primer:
What Pharmacists and HCPs Should Know
Accreditation Number: PHA-2018-0460-050

Validity: 11 January 2021 to 10 January 2022
Number of CPD units Approved: 1 Pharmacy CPD unit
Major CPD Area: Professional Practice
Media: Internet
Program Type: On Demand Webinar
Image from https://scitechdaily.com/vapers-show-chemical-changes-in-their-dna-that-are-linked-to-cancer/
E-cigarettes Primer
What Pharmacists and HCPs Should Know
Louie Fernand D. Legaspi, MHSS, RPh

Assistant Professor
De La Salle Medical and Health Sciences Institute
College of Pharmacy
City of Dasmarinas, Cavite
Image from https://scitechdaily.com/vapers-show-chemical-changes-in-their-dna-that-are-linked-to-cancer/
About the Speaker Louie Fernand Legaspi

MHSS, RPh
De La Salle Assistant Professor

Medical and Health Chair, Department of Clinical/
Sciences Institute Practical Training and Internship
Philippine Chair, PharmaCEASE
Pharmacists Smoking Cessation Advocacy
Association
1
Disclosure
None to disclose
Disclaimer
The opinions and recommendations expressed

by the author and other experts whose contribution is
included in this program are their own.
This program is created for educational purposes

only.
Define key terms related to e-cigarettes
Describe e-cigarettes including various devices used, flavors,

nicotine content, etc.
Recognize the potential dangers of e-cigarette use based on

published evidences
Objectives Describe the strategies manufacturers and sellers of e-cigarettes

employ to increase use among adolescents, such as deceptive and
creative marketing strategies
Explain EVALI (E-cigarette or Vape-products use Associated Lung

Injury)
Appraise the significant role of the pharmacist to reduce the use of

e-cigarettes.
2
Outline
Section 1. Definition of Terms
Section 2. Overview of Vaping and E-cigarette
Section 3. Is Vaping for Everyone?
Section 4. Health Risks of Vaping and EVALI
Section 5. The Pharmacist’s Role in E-cigarette Use
Section 6. Key Takeaway
Section 1
Definition of Terms
This Photo by Unknown Author is licensed under CC BY-SA
Electronic Nicotine Delivery Systems/Electronic

Non-nicotine Delivery Systems (ENDS/ENNDS)
Battery-powered devices; do not burn or use tobacco leaves;

• Vaporizes a solution that is inhaled by user
Nicotine – common drug used

• Marijuana and other drugs
Solutions & emissions contain other chemicals (toxicants)
Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems. (2015). Retrieved from
http://www9.who.int/tobacco/communications/statements/eletronic_cigarettes/en/
3
Electronic Liquid (e-liquid)
Common term for the E-cigarette refill liquid and

sometimes referred to as Juice or e-juice. 1
Main constituents are:
a) Nicotine (with or without) – active ingredient (THC),

which content varies from product to product
b) Propylene glycol (PEG) or vegetable glycerin (VG) –

humectants that produce aerosols that simulate tobacco
smoking
c) Flavoring agents
Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems. (2015). Retrieved from
10
Vaping
• The use of e-cigarettes simulating the experience of

smoking1
• Use of e-cigarettes; also referred to as “juuling” or

“dabbing”
• Process of inhaling the aerosol generated by heating the

e-liquid using an e-cigarette
Gotts, J. E., Jordt, S. E., McConnell, R., & Tarran, R. (2019). What are the respiratory effects of e-
cigarettes?. BMJ 2019; 366:l5275.
11
Outline
Section 4. Health Risks of Vaping
12
4
Section 2 Optional but strongly recommended:

Overview of Vaping and photo representing this part
E-cigarettes
This Photo by Unknown Author is licensed under CC BY-NC-ND
13
History of E-cigarette
1st documented reference

1930 to an e-cigarette: patent
granted to Joseph
Robinson
Herbert A. Gilbert: “smokeless

non-tobacco cigarette”; safer
1965
method of smoking
Image from: https://patents.google.com/patent/US3200819
CASAA. (n.d.) A Historical Timeline of Electronic Cigarettes. Retrieved from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/

White, A. (2018). Plans for the First E-cigarette Went Up in Smoke 50 Years Ago. Smithsonian Magazine. Retrieved from
https://www.smithsonianmag.com/innovation/plans-for-first-e-cigarette-went-up-in-smoke-50-years-ago-180970730/
14
History of E-cigarette
Numerous patents for nicotine
1990s inhaler devices filed by tobacco
companies and individual inventors;
few are like modern e-cigarettes
The first device in the recent

innovation in e-cigarette was
developed by Hon Lik, a 2003
Chinese pharmacist
Hon Lik, inventor of the e-cigarette; Photograph: Stefan Wermuth/Reuters
CASAA. (n.d.). A Historical Timeline of Electronic Cigarettes. Retrieved from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/
15
5
The Anatomy of an E-cigarette
E-cigarette devices are composed of:

• a reservoir for holding a solution that typically
contains nicotine
• a mouthpiece through which the user puffs
• an atomizer or heating element
• a battery: power source
Photo from E-cigarette, or Vaping, Products Visual Dictionary by the CDC.

Centers for Disease Control and Prevention. (2016). E-Cigarette Use Among Youth and Young Adults.
A Report of the Surgeon General. Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/e-
cigarettes/pdfs/2016_sgr_entire_report_508.pdf
16
These cartridges/pods contain

The anatomy of a Pod-based E-cigarette NICOTINE!
Cartridges/Pods
P
H
I
X
J
U
U
L
Covers
Devices with Rechargeable Battery
Stanford University. (n.d.). Modules for tobacco and nicotine education. Retrieved from https://med.stanford.edu/tobaccopreventiontoolkit
17
The anatomy of a Pod-based E-cigarette
1 ½ to 2 packs
1 JUUL pod = 41.3 mg Nicotine =
cigarettes
This Photo by Unknown Author is licensed under CC BY-SA-NC This Photo by Unknown Author is licensed under CC BY-SA
1 PHIX pod = 75 mg Nicotine

Image from http://phixpods.blogspot.com/2018/12/phix-pods-alternative-to-quit-smoking.html
JUUL Device Basics. (n.d.). Retrieved from https://support.juulvapor.com/home/learn/faqs/juulpods-juice
PHIX. FAQ: How much nicotine is in a PHIX/ PHIX cost, cigarette alternatives. Retrieved from https://phixvapor.com/pages/faq
18
6
Different names, same device
Photo from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
Centers for Disease Control and Prevention. (2020). Smoking and Tobacco Use: About Electronic Cigarettes (E-
Cigarettes). Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
19
ENDS look like regular

1st Gen cigarettes, pipes, or
cigars
The differences in design and

Pens, large cylinders or
2nd Gen engineering of the products are
“tank systems”
key factors in the size,
distribution, and amount of
aerosol particles and the
More custom variability in levels of
modification, i.e. chemicals and nicotine
3rd Gen
adjusting higher heat present in the e-liquid/aerosol
temperatures, “mods” and delivered to the user.
Resembles USB flash

4th Gen
drives, “pod-mods”
Photo by Mandie Mills, CDC
Centers for Disease Control and Prevention. (2016). E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General.
Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf
Rigotti, NA, Kalkhoran, S. (2020). Vaping and e-cigarettes. UpToDate. Retrieved from https://www.uptodate.com/contents/vaping-
and-e-cigarettes?topicRef=122671&source=related_link
20
E-liquids
Most often flavored
• Tobacco
7,700 • Mint
flavors • Coffee
Widespread availability and
available • Fruit
popularity of flavored e-cigarette is
• Alcoholic drink
a key concern regarding potential
public health implications
Generally Many have GRAS certification
Photo by Mandie Mills, CDC.
Recognized for use in food products, but
as Safe there is little research to suggest
(GRAS) these are safe for vaping
US Food and Drug Administration. (2019). Generally recognized as safe (GRAS). Retrieved from
https://www.fda.gov/food/food-ingredients-packaging/generally-recognized-safe-gras
21
7
Quick comparison of traditional vs electronic cigarette
• Works by combustion • Works by convection or

• Smoke; unpleasant smell conduction
• Ingredients: nicotine • Smokeless, pleasantly
and carcinogenic aromatic
substances like: • Ingredients: nicotine
• Hydrogen Cyanide, and substances like:
Formaldehyde, Lead,
• Propylene Glycol
Arsenic, Ammonia,
Benzene, Carbon • Vegetable Glycerin
Monoxide, Nitrosamines, • Acetaldehyde
Polycyclic aromatic • Nitrosamines
hydrocarbons • Others related to flavoring
• Health and safety • Lower health and safety
concerns backed up by concerns but lacks
scientific evidence concrete evidences
Cigarette E-Cigarette
Matthews, C. (2016). Vaping vs Smoking. Vaping Daily. Retrieved from https://vapingdaily.com/smoking-vs-vaping/
22
Both traditional and electronic cigarette pose a threat to health
Photos from:
https://www.compoundchem.com/2014/05/01/the-chemicals-in-cigarette-smoke-their-effects/
https://www.bishopwatterson.com/academics/guidance/personalsocial-guidance/
23
Is vaping SAFER than smoking?
Research so far suggests that vaping devices

might be less harmful than combustible
cigarettes when people who regularly smoke
switch to them as a complete replacement.10
What are the long-health effects and

public health concerns?
Nicotine content?
• Nicotine - highly addictive principle Photo by Giovanni Randisi on Unsplash and gawriloff/iStock/Getty Images Plus
National Institute on Drug Abuse. (2020, January). Vaping Devices (Electronic Cigarettes). Retrieved from
https://www.drugabuse.gov/publications/drugfacts/vaping-devices-electronic-cigarettes
24
8
Slide 23
1 Reference for the discussion pertaining to this slide?

periwinkle2, 5/15/2020
From tobaccopreventiontoolkit.stanford.edu
1 Pack of Cigarettes 1 JUUL pod 1 Puff bar 1 Suorin pod

≈20 mg of nicotine ≈41.3 mg of nicotine ≈50 mg of nicotine ≈90 mg of nicotine
≈20 ≈41 ≈50 ≈90

CIGARETTES CIGARETTES CIGARETTES
CIGARETTES
Stanford University. (n.d.). Modules for tobacco and nicotine education.

Retrieved from https://med.stanford.edu/tobaccopreventiontoolkit
25
Smokescreen Strategy • Attract people by relating their products

to a positive image
• Make the product enjoyable with the use of

flavors
• Increase in a powerful addictive substance

(nicotine) so people get hooked
• Conceals or minimizes the bad health effect of

e-cigarette
Photo from https://www.takeapart.org/wheretheressmoke/
• Social media targeting or influence marketing like

what the tobacco industry has been doing in the past
26
E-cigarette products regulations vary by country.
WHO: regulations should stop promotion to

youth, minimize potential health risks to users and
non-user, stop unproven health claims, and protect
existing tobacco control efforts.11
E-cigarette This Photo by Unknown Author is licensed under CC BY-SA-NC
Regulations Not accepted by the FDA as a nicotine

replacement therapy for smoking
cessation.7
• Not enough hard evidence to prove health claims
as harmless
• Numerous chemicals in e-liquids: carcinogenic
Rigotti, NA, Kalkhoran, S. (2020). Vaping and e-cigarettes. UpToDate. Retrieved from
https://www.uptodate.com/contents/vaping-and-e-cigarettes?topicRef=122671&source=related_link
WHO Framework Convention on Tobacco Control. (2014).Report on electronic nicotine delivery systems. Retrieved from
https://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10Rev1-en.pdf
27
9
E-cigarette
Regulations In the Philippines, currently, there are nine (9) bills filed for
the regulation of e-cigarettes.
• Three laws: regulating ENDS and its related products

• RA 7394, RA 9711 and AO 2014-0008
• Under RA 7394 and AO 2014-0008

• Vaping machine falls under the definition of a
device
• E-liquid falls within the definition of drugs and shall
be regulated as a medicinal product.
Health Justice Philippines. (2019). Tobacco and E-Cigarette Industry Interference in Public Health Policy in the Philippines. p. 17
28
Outline
Section 4. Health Risks of Vaping
29
Section 3
Is Vaping for Everyone?
This Photo by Unknown Author is licensed under CC BY
30
10
Who uses e-cigarettes?

Statistics in the US
Center for Disease Control and Prevention. (n.d.). Electronic Cigarettes Fact Sheet. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-
cigarettes/pdfs/Electronic-Cigarettes-Infographic-508.pdf
31

2015 Global Adult 2015 Global Youth
Statistics in the Philippines Tobacco Survey Tobacco Survey
adult users of
e-cigarettes
Students ages 13 – 15
Adults currently tried or have
smoking tobacco experimented with e-
cigarettes (one or two
puffs)
40.3% 5.1%
Department of Health. (2015). Philippines Global Adult Tobacco Survey (GATS): Country Report 2015.
Retrieved from https://www.doh.gov.ph/sites/default/files/publications/2015GATSCountryReport_0.pdf
Department of Health. (2015). Global Youth Tobacco Survey Philippines 2015: Fact Sheet. Retrieved from
https://www.doh.gov.ph/sites/default/files/publications/2015GYTSFinalFactSheet_1.pdf
32

Old smokers
Current or former adult

smokers who want to:
• Stop nicotine cravings

• Quit smoking
• Cut down on tobacco cigarettes
Non-smokers who use

e-cigarette for
recreational use and
social image
Images from: https://www.umms.org/capital/health-services/respiratory/tobacco-use-prevention-cessation

https://blog.mtbakervapor.com/how-cool-is-vaping-vaping-is-cool/
Cigarettes: What You Need to Know. (2015). Retrieved from http://headsup.scholastic.com/students/e-cigarettes-what-you-need-to-know
33
11
Slide 32
2 source of photo?
periwinkle2, 5/18/2020
Who uses e-cigarettes? REASONS

Replacement to old smokers
Easy availability of these devices
Alluring advertisements
Young people as the perfect
replacement customers
Variety of e-liquid flavors
Photo by Rainer Ridao for Unsplash
Belief that they are safer than cigarettes

If young people get hooked early in
life, they’ll have them as customers Easy to hide from teachers and parents
for years to come (no traceable scent; often disguised as
flash drives)
National Institute on Drug Abuse. (2020, January). Vaping Devices (Electronic Cigarettes). Retrieved from
https://www.drugabuse.gov/publications/drugfacts/vaping-devices-electronic-cigarettes
34
Diversity of flavors
appeal to youth
• Effective advertising strategy
• Attracts young customers interested
in sweet flavors and bright colors
Evidences of
danger are piling
• Flavors can impair lung function,
increase the risk of heart diseases, American Thoracic Society. (2018, May 23). Widely used e-cigarette flavoring impairs lung function. Science Daily.
Retrieved from https://www.sciencedaily.com/releases/2018/05/180523172310.htm
and damage blood vessels. Stanford School of Medicine News Center. (2019, May 27). E-cigarette use, flavorings may increase heart disease risk,
study finds. Retrieved from https://med.stanford.edu/news/all-news/2019/05/e-cigarette-use-and-flavorings-may-
increase-heart-disease-risk.html
University of Pennsylvania School of Medicine. (2019, August 20). Nicotine-free e-cigarettes can damage blood vessels:
Single instance of vaping immediately leads to reduced vascular function. ScienceDaily. Retrieved from
www.sciencedaily.com/releases/2019/08/190820101601.htm
35
Why do smokers and non-smokers vape?

This Photo by Unknown Author is licensed under CC BY-SA-NC
Smoking Cessation Recreational Use

A research by Ayers et al., using content
analysis of Twitter in 2012-2015 (sample of
2900 tweets per year). The reason for using
For smokers, they found ‘vaping’ as an ENDS in 2015 are as follows:
alternative to tobacco smoking as it • Social image
was being advertised as “harmless” • Quitting combustibles
and a tool to help them quit smoking. • Flavor choices
• Can vape indoors
• Safe to use
• Favorable odor
• Low cost
American Thoracic Society. (2018, May 23). Widely used e-cigarette flavoring impairs lung function. Science Daily. Retrieved from
https://www.sciencedaily.com/releases/2018/05/180523172310.htm
Ayers, J. W., Leas, E. C., Allem, J., Benton, A., Dredze, M., Althouse, B. M., et.al. (2017, March 01). Why do people use electronic nicotine delivery systems
(electronic cigarettes)?: A content analysis of Twitter, 2012 - 2015. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170702
36
12
Use of e-cigarettes increase the likelihood (about 4

times) of the youth to use cigarettes later in their
life
Do people This Photo by Unknown Author is licensed under CC BY
who vape,
smoke as National Academics of Sciences, Engineering and
Medicine (NASEM) report
well? • E-cigarette use increases the risk of the youth to
initiate combustible cigarettes
• E-cigarette use increases the intensity and
frequency of subsequent use of combustible
cigarettes
Berry, K. M., Fetterman, J. L., Benjamin, E. J., Bhatnagar, A., Barrington-Trimis, J. L., Leventhal, A. M., & Stokes, A. (2019). Association of electronic
cigarette use with subsequent initiation of tobacco cigarettes in US youths. JAMA network open, 2(2), e187794-e187794.
National Academies of Sciences, Engineering, and Medicine.(2018). Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies
Press. DOI: 10.17226/24952
37
Outline
Section 4. Health Risks of Vaping and EVALI
38
Section 4
Health Risks
39
13
The Recent Lung Epidemic

in the US
February 18, 2020
2,807 hospitalized e-cigarette or vaping
product use-associated lung injury (EVALI)
cases or deaths reported to CDC in the US
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-
disease/images/lung-injury-wide-tall.jpg
68 deaths have been confirmed in 29

states and the District of Columbia
November 8, 2019
CDC report: lung fluids from 29 EVALI
patients in 10 states found Vitamin E acetate
in some THC-infused vape products
This Photo by Unknown Author is licensed under CC BY-NC
Centers for Disease Control and Prevention. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping,
Products. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
40
E-cigarette or Vape-products use

Associated Lung Injury (EVALI)
Vaping Associated 2019: an acute or

Pulmonary Injury subacute respiratory
(VAPI) illness that can be
severe and life-
threatening
Key risk factor:

use of e-cigarette or Other unknown
similar product additives may be
responsible and further
work is needed
Rigotti, NA, Kalkhoran, S. (2020). Vaping and e-cigarettes. UpToDate. Retrieved from https://www.uptodate.com/contents/vaping-
and-e-cigarettes?topicRef=122671&source=related_link
Centers for Disease Control and Prevention. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or
Vaping, Products. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
41
Clinical Features of EVALI

Respiratory symptoms -
cough, shortness of breath, or Symptoms:
chest pain • Some developed over a few days
• Others developed over several
weeks.
Gastrointestinal symptoms This Photo by Unknown Author is licensed under CC BY -NC-ND
- nausea, vomiting, stomach

pain, or diarrhea
A lung infection does not appear

Nonspecific constitutional to be causing the symptoms.
symptoms – fever, chills, or
weight loss
Layden, J. E., Ghinai, I., Pray, I., Kimball, A., Layer, M., Tenforde, M. W., . . . Meiman, J. (2020). Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Final
Report. New England Journal of Medicine, 382(10), 903-916. doi:10.1056/nejmoa1911614
Rigotti, NA, Kalkhoran, S. (2020). Vaping and e-cigarettes. UpToDate. Retrieved from https://www.uptodate.com/contents/vaping-and-e-
cigarettes?topicRef=122671&source=related_link
Centers for Disease Control and Prevention. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Retrieved from
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
42
14
First case of EVALI in the

Philippines
The Health Department announced the
1st case of EVALI— recorded in Visayas
Patient: 16-year-old girl

E-cigarette use: six months
E-cigarette used "concurrently with

cigarettes"— which the DOH tagged as
"dual use.”
Patient met the case criteria for EVALI

per US CDC guidelines
Department of Health. (2019, November 15). DOH-FDA RECEIVES FIRST PH CASE REPORT OF E-CIGARETTE OR VAPE-ASSOCIATED LUNG INJURY
(EVALI): Department of Health website. Retrieved from https://www.doh.gov.ph/press-release/DOH-FDA-recieves-first-PH-case-report-of-E-Cigarette-or-
Vape-Associated-Lung-Inury(EVALI)
43
Nicotine –potentially harm brain development

• “nicotine-free” e-cigarettes have been found to contain
nicotine.
Chemicals in e-liquids – carcinogenic, pose a health

risk and other detrimental effects
More This Photo by Unknown Author is licensed under CC BY-SA-NC
concerns Explosions and Although there recharging

burns while are only limited data due
the devices,
available regarding the direct impact of
to defective batteries.
e-cigarettes in lung function whether
after chronic or acute, its products including
This Photo
e-liquid should be regulated to prevent

by Unknown Author is licensed under CC BY-NC-ND
EVALI? detrimental
Accidental exposure to liquideffects to health. has caused
from e-cigarettes
acute nicotine poisoning in children and adults
This Photo by Unknown Author is licensed under CC BY-ND
Vaping during pregnancy could harm a developing

fetus.
Centers for Disease Control and Prevention. (2016). E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Retrieved from
https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf
Shmerling, R. (2019, December 10). Can vaping damage your lungs? What we do (and don't) know. Retrieved from https://www.health.harvard.edu/blog/can-
vaping-damage-your-lungs-what-we-do-and-dont-know-2019090417734
44
Secondhand Aerosol Nicotine

Heavy
Metals
Sources:
Ultrafine
Burning or heating tobacco Particles
(cigarette, cigar, pipe, hookah, or
electronic cigarette)
Air a smoker exhales while Volatile

smoking Organic
Cmpds
Enters the body through:

Cancerous
1. Inhalation
Chemicals
2. Skin absorption
American Thoracic Society. (2020). What are second and third-hand smoke and vaping aerosols. Patient Information Series. [PDF}.
Retrieved from https://www.thoracic.org/patients/patient-resources/resources/second-hand-smoke.pdf
45
15
Thirdhand Aerosol
Third-hand smoke – smoke that
Thirdhand Smoke
stays in the following long after
smoking:
The residual nicotine and
• Clothes
other • Drapes
chemicals left on
indoor surfaces
• Furniture by
• Walls
tobacco
• Bedding smoke.
• Dust
• Carpets • Vehicles, and
• Other surfaces
Thirdhand Smoke Exposure
• Touching contaminated
Residuesurfaces;
+ commonor indoor pollutants =
• Breathing
toxic mix posing ainpotential
the off-gassing
health
hazard from these
to non surfaces.
smokers
Nicotine & other chemicals
Hays, JT. (2017). What is third-hand smoke, and why is it a concern?. Mayo Clinic. Retrieved from
https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/third-hand-smoke/faq-20057791
American Thoracic Society. (2020). What are second and third-hand smoke and vaping aerosols. Patient Information
Series. [PDF}. Retrieved from https://www.thoracic.org/patients/patient-resources/resources/second-hand-smoke.pdf
46
Secondhand Exposure Thirdhand Exposure
Healthy, non-smoking adults 

30 minutes exposure to
According to a study, there is a
secondhand emissions of e-
30 cigarette  sensory irritation risk for thirdhand exposure to
MINUTES (eyes, nose and throat), nicotine from e-cigarettes. The
dryness and shortness of exposure levels vary
breath
depending on the surface and
This Photo by Unknown Author is licensed under CC BY-SA-NC
e-cigarette brand.
Non-smokers, passively
exposed to e-cigarette
emissions at least 2
hours/day nicotine was
absorbed into their body in Tzortzi, A., Teloniatis, S., Matiampa, G., Bakelas, G., Tzavara, C., Vyzikidou, V. K., ... & Castellano,
significant amounts Y. (2020). Passive exposure of non-smokers to E-Cigarette aerosols: Sensory irritation, timing and
association with volatile organic compounds. Environmental Research, 182, 108963.
This Photo by Unknown Author is licensed under CC BY-SA-NC Ballbè, M., Martínez-Sánchez, J. M., Sureda, X., Fu, M., Pérez-Ortuño, R., Pascual, J. A., ... &
Fernández, E. (2014). Cigarettes vs. e-cigarettes: Passive exposure at home measured by means of
airborne marker and biomarkers. Environmental research, 135, 76-80.
Goniewicz, M. L., & Lee, L. (2014). Electronic cigarettes are a source of thirdhand exposure to
nicotine. Nicotine & Tobacco Research, 17(2), 256-258
47
Nicotine Addiction
NICOTINE Concentration significantly

varies between different e-
liquid brands
A highly addicting
compound leading to
nicotine dependence • The variability of
concentration of nicotine
content pose a health risk
(0,3,6,12,18,24,30,36 mg/ml)
Alternatively, it can • “Nicotine Free” but have
be used for smoking nicotine in variable amounts
cessation
Image from http://bestejuice.com/how-many-cigarettes-are-in-a-30ml-bottle-of-e-liquid/
World Health Organization. (2015) Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems. Retrieved from
Centers for Disease Control and Prevention. (2016). E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Retrieved from
Center for Disease Control and Prevention. (n.d.). Electronic Cigarettes Fact Sheet. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-
cigarettes/pdfs/Electronic-Cigarettes-Infographic-508.pdf
48
16
Image Credit: National Institute of Health via Wikimedia Commons and tobaccopreventiontoolkit.stanford.edu
Nicotine in the brain Synapse

Nerve Cell
with
Acetylcholine
Nicotine mimics a naturally produced
chemical in the brain and easily binds to its Acetylcholine
Receptors
receptors
When those receptors get filled, it sets off a

chain reaction that leads the brain to feel Nicotine
pleasure
Regardless of device used, nicotine hijacks the

“pleasure pathway” tricking the brain into
interpreting the chemical signal as pleasurable
and necessary
Continuing to use nicotine in any form

will result in addiction.
National Institute on Drug Abuse. (2020). Is nicotine addictive? Retrieved from https://www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-
cigarettes/nicotine-addictive
Coalition Against Drug Abuse. (n.d.). Drugs and Rewards Pathways: The Science Behind Addiction. Retrieved from http://drugabuse.com/visualize/the-
science-behind-addiction/
49
Nicotine in the body
Rewires and
changes the
brain activity Heart beats faster
due to “fight or
flight” response
Trouble breathing
& damage to lungs Increased
acid reflux
Mishra, A., Chaturvedi, P., Datta, S., Sinukumar, S., Joshi, P., & Garg, A. (2015). Harmful effects of nicotine. Indian journal of medical and paediatric
oncology : official journal of Indian Society of Medical & Paediatric Oncology, 36(1), 24–31. https://doi.org/10.4103/0971-5851.151771
50
Outline
Section 4. Health Risks
51
17

The Pharmacist’s Role in photo representing this part
E-cigarette Use
52
Pharmacist’s Role in Vaping and Vaping related Illness
Educate themselves regarding the signs,

symptoms, and consequences of vaping
to enhance their competencies & skills on
patient counseling
Provide education regarding the risk and

consequences of vaping
• Terminology, vaping products, scientific data on

the potential harm of e-cigarette on health
Image from https://www.allalliedhealthschools.com/blog/how-to-become-a-pharmacist/
• Tackling misconceptions
• Switching to vaping from regular smoking
as it cuts nicotine consumption Poindexter, L., McCoy, B., & Chater, R. (2019, December 5). The Community Pharmacist: Frontline
Care Provider for Vaping. Retrieved from https://www.pharmacytimes.com/news/the-community-
• Harm reduction and elimination pharmacist-frontline-care-provider-in-the-vaping-epidemic
Bonner, L. (2019, November). What pharmacists need to know about vaping and vaping-related
lung illness. Retrieved from https://www.pharmacytoday.org/article/S1042-0991(19)31226-
5/fulltext
53
Pharmacist’s Role in Vaping and Vaping related Illness
Advise and refer vaping patients presenting

pulmonary symptoms to seek medical care
urgently
Establish themselves as a resource for

patients who are interested in quitting
• Encourage smokers or vape users to quit smoking

and to titrate off these products to reduce
withdrawal symptoms, making them more
comfortable while they are quitting.
• Incorporate motivational interviewing into
counseling and assist in behavioral changes to Poindexter, L., McCoy, B., & Chater, R. (2019, December 5). The Community Pharmacist:
enhance their chances of quitting. Frontline Care Provider for Vaping. Retrieved from https://www.pharmacytimes.com/news/the-
community-pharmacist-frontline-care-provider-in-the-vaping-epidemic
Bonner, L. (2019, November). What pharmacists need to know about vaping and vaping-related
lung illness. Retrieved from https://www.pharmacytoday.org/article/S1042-0991(19)31226-
5/fulltext
54
18
Outline
Section 4. Health Risks
55

Key Takeaway photo representing this part
56
Summary
Using an e-cigarette is sometimes called “vaping.”
E-cigarettes come in many shapes and sizes. Most have a battery, a heating element,
and a place to hold a liquid.
E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine,

flavorings, and other chemicals that help to make the aerosol.
Users inhale this aerosol into their lungs.
Exposure to the aerosol can extend to secondhand and thirdhand smoking.
The two most common reasons why non-smokers use e-cigarette are :
• Variety of e-liquids flavors available
• Social impact or image
57
19
Summary
Evidences show that non-smokers who use e-cigarettes are highly likely to use
combustible cigarettes as well, later in their life.
Manufacturer strategies involve advertising e-cigarettes as less harmful & as a tool

for smoking cessation
Chemicals found in both e-liquid and its aerosol form vary including its nicotine
content which pose health risks to young people and adults, leading to addiction
and other health problems.
58
Summary
If e-cigarettes and its related products are to be regulated in the Philippines,
• e-cigarettes: medical devices
• e-liquids: drug
There are no manufacturing standards in making e-liquids and it varies from

vendor to vendor.
• Nicotine content are highly variable
• Most chemicals found in e-liquids are not stated in the label of ingredients.
• Flavorings used in e-liquids are GRAS for ingestion but not widely tested if safe
via inhalation
The masses, specifically teenagers are being hooked to vaping mainly due to
marketing strategies.
59
Key Takeaway
People trying to quit smoking or using tobacco products should try proven tobacco
cessation therapies before considering using e-cigarettes
People who do not currently smoke or use tobacco products should not use e-
cigarettes.
The long-term health effects of e-cigarettes are not well understood yet. But the
science clearly indicates vaping is not a safe or healthy alternative to smoking.
Overall, providing education regarding the risks and consequences to patients

along with a personalized plan to impart the support necessary to hollow the
epidemic of vaping is key.
60
20
References
1. Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems. (2015). Retrieved from http://www9.who.int/tobacco/communications/statements/eletronic_cigarettes/en/
2. Gotts, J. E., Jordt, S. E., McConnell, R., & Tarran, R. (2019). What are the respiratory effects of e-cigarettes?. BMJ 2019; 366:l5275.
3. CASAA. (n.d.) A Historical Timeline of Electronic Cigarettes. Retrieved from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/

4. White, A. (2018). Plans for the First E-cigarette Went Up in Smoke 50 Years Ago. Smithsonian Magazine. Retrieved from https://www.smithsonianmag.com/innovation/plans-for-
first-e-cigarette-went-up-in-smoke-50-years-ago-180970730/
5. Centers for Disease Control and Prevention. (2016). E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Retrieved from
6. Stanford University. (n.d.). Modules for tobacco and nicotine education. Retrieved from https://med.stanford.edu/tobaccopreventiontoolkit
7. JUUL Device Basics. (n.d.). Retrieved from https://support.juulvapor.com/home/learn/faqs/juulpods-juice
8. PHIX. FAQ: How much nicotine is in a PHIX/ PHIX cost, cigarette alternatives. Retrieved from https://phixvapor.com/pages/faq
9. Centers for Disease Control and Prevention. (2020). Smoking and Tobacco Use: About Electronic Cigarettes (E-Cigarettes). Retrieved from
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
10. Rigotti, NA, Kalkhoran, S. (2020). Vaping and e-cigarettes. UpToDate. Retrieved from https://www.uptodate.com/contents/vaping-and-e-
cigarettes?topicRef=122671&source=related_link
11. US Food and Drug Administration. (2019). Generally recognized as safe (GRAS). Retrieved from https://www.fda.gov/food/food-ingredients-packaging/generally-recognized-
safe-gras
12. Matthews, C. (2016). Vaping vs Smoking. Vaping Daily. Retrieved from https://vapingdaily.com/smoking-vs-vaping/
13. National Institute on Drug Abuse. (2020, January). Vaping Devices (Electronic Cigarettes). Retrieved from https://www.drugabuse.gov/publications/drugfacts/vaping-devices-
electronic-cigarettes
14. WHO Framework Convention on Tobacco Control. (2014).Report on electronic nicotine delivery systems. Retrieved from
https://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10Rev1-en.pdf
15. Health Justice Philippines. (2019). Tobacco and E-Cigarette Industry Interference in Public Health Policy in the Philippines. p. 17
61
References
16. Center for Disease Control and Prevention. (n.d.). Electronic Cigarettes Fact Sheet. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-
Cigarettes-Infographic-508.pdf
17. Department of Health. (2015). Philippines Global Adult Tobacco Survey (GATS): Country Report 2015. Retrieved from
https://www.doh.gov.ph/sites/default/files/publications/2015GATSCountryReport_0.pdf
18. Department of Health. (2015). Global Youth Tobacco Survey Philippines 2015: Fact Sheet. Retrieved from
https://www.doh.gov.ph/sites/default/files/publications/2015GYTSFinalFactSheet_1.pdf
19. Cigarettes: What You Need to Know. (2015). Retrieved from http://headsup.scholastic.com/students/e-cigarettes-what-you-need-to-know
20. National Institute on Drug Abuse. (2020, January). Vaping Devices (Electronic Cigarettes). Retrieved from https://www.drugabuse.gov/publications/drugfacts/vaping-devices-
electronic-cigarettes
21. American Thoracic Society. (2018, May 23). Widely used e-cigarette flavoring impairs lung function. Science Daily. Retrieved from
https://www.sciencedaily.com/releases/2018/05/180523172310.htm
22. Stanford School of Medicine News Center. (2019, May 27). E-cigarette use, flavorings may increase heart disease risk, study finds. Retrieved from
https://med.stanford.edu/news/all-news/2019/05/e-cigarette-use-and-flavorings-may-increase-heart-disease-risk.html
23. University of Pennsylvania School of Medicine. (2019, August 20). Nicotine-free e-cigarettes can damage blood vessels: Single instance of vaping immediately leads to reduced
vascular function. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2019/08/190820101601.htm
24. Ayers, J. W., Leas, E. C., Allem, J., Benton, A., Dredze, M., Althouse, B. M., et.al. (2017, March 01). Why do people use electronic nicotine delivery systems (electronic cigarettes)?: A
content analysis of Twitter, 2012 - 2015. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170702
25. Berry, K. M., Fetterman, J. L., Benjamin, E. J., Bhatnagar, A., Barrington-Trimis, J. L., Leventhal, A. M., & Stokes, A. (2019). Association of electronic cigarette use with subsequent
initiation of tobacco cigarettes in US youths. JAMA network open, 2(2), e187794-e187794.
26. National Academies of Sciences, Engineering, and Medicine.(2018). Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press.
DOI: 10.17226/24952
27. Centers for Disease Control and Prevention. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Retrieved from
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
62
References
28. Layden, J. E., Ghinai, I., Pray, I., Kimball, A., Layer, M., Tenforde, M. W., . . . Meiman, J. (2020). Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Final
Report. New England Journal of Medicine, 382(10), 903-916. doi:10.1056/nejmoa1911614
29. Department of Health. (2019, November 15). DOH-FDA RECEIVES FIRST PH CASE REPORT OF E-CIGARETTE OR VAPE-ASSOCIATED LUNG INJURY (EVALI): Department of
Health website. Retrieved from https://www.doh.gov.ph/press-release/DOH-FDA-recieves-first-PH-case-report-of-E-Cigarette-or-Vape-Associated-Lung-Inury(EVALI)
30. Shmerling, R. (2019, December 10). Can vaping damage your lungs? What we do (and don't) know. Retrieved from https://www.health.harvard.edu/blog/can-vaping-damage-
your-lungs-what-we-do-and-dont-know-2019090417734
31. American Thoracic Society. (2020). What are second and third-hand smoke and vaping aerosols. Patient Information Series. [PDF}. Retrieved from
https://www.thoracic.org/patients/patient-resources/resources/second-hand-smoke.pdf
32. Hays, JT. (2017). What is third-hand smoke, and why is it a concern?. Mayo Clinic. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-
answers/third-hand-smoke/faq-20057791
33. Tzortzi, A., Teloniatis, S., Matiampa, G., Bakelas, G., Tzavara, C., Vyzikidou, V. K., ... & Castellano, Y. (2020). Passive exposure of non-smokers to E-Cigarette aerosols: Sensory
irritation, timing and association with volatile organic compounds. Environmental Research, 182, 108963.
34. Ballbè, M., Martínez-Sánchez, J. M., Sureda, X., Fu, M., Pérez-Ortuño, R., Pascual, J. A., ... & Fernández, E. (2014). Cigarettes vs. e-cigarettes: Passive exposure at home measured
by means of airborne marker and biomarkers. Environmental research, 135, 76-80.
35. Goniewicz, M. L., & Lee, L. (2014). Electronic cigarettes are a source of thirdhand exposure to nicotine. Nicotine & Tobacco Research, 17(2), 256-258
36. World Health Organization. (2015) Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems. Retrieved from
37. Center for Disease Control and Prevention. (n.d.). Electronic Cigarettes Fact Sheet. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-
Cigarettes-Infographic-508.pdf
38. National Institute on Drug Abuse. (2020). Is nicotine addictive? Retrieved from https://www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-
cigarettes/nicotine-addictive
39. Coalition Against Drug Abuse. (n.d.). Drugs and Rewards Pathways: The Science Behind Addiction. Retrieved from http://drugabuse.com/visualize/the-science-behind-addiction/
63
21
References
40. Mishra, A., Chaturvedi, P., Datta, S., Sinukumar, S., Joshi, P., & Garg, A. (2015). Harmful effects of nicotine. Indian journal of medical and paediatric oncology : official journal of
Indian Society of Medical & Paediatric Oncology, 36(1), 24–31. https://doi.org/10.4103/0971-5851.151771
41. Poindexter, L., McCoy, B., & Chater, R. (2019, December 5). The Community Pharmacist: Frontline Care Provider for Vaping. Retrieved from
https://www.pharmacytimes.com/news/the-community-pharmacist-frontline-care-provider-in-the-vaping-epidemic
42. Bonner, L. (2019, November). What pharmacists need to know about vaping and vaping-related lung illness. Retrieved from https://www.pharmacytoday.org/article/S1042-
0991(19)31226-5/fulltext
64
谢谢
고맙습니다
ありがとうございました
Thank you!
Maraming salamat
Gracias
Merci
65
22

E-Cigarettes Primer

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E-cigarettes Primer: What HCPs and 11 January 2021 – 10 January 2022

Pharmacists Should Know

Accreditation Number: PHA-2018-0460-050

Image from https://scitechdaily.com/vapers-show-chemical-changes-in-their-dna-that-are-linked-to-cancer/

Louie Fernand D. Legaspi, MHSS, RPh

Image from https://scitechdaily.com/vapers-show-chemical-changes-in-their-dna-that-are-linked-to-cancer/

About the Speaker Louie Fernand Legaspi

De La Salle Assistant Professor

The opinions and recommendations expressed

This program is created for educational purposes

Define key terms related to e-cigarettes

Describe e-cigarettes including various devices used, flavors,

Recognize the potential dangers of e-cigarette use based on

Objectives Describe the strategies manufacturers and sellers of e-cigarettes

Explain EVALI (E-cigarette or Vape-products use Associated Lung

Appraise the significant role of the pharmacist to reduce the use of

Section 1. Definition of Terms

Section 2. Overview of Vaping and E-cigarette

Section 3. Is Vaping for Everyone?

Section 4. Health Risks of Vaping and EVALI

Section 5. The Pharmacist’s Role in E-cigarette Use

Section 6. Key Takeaway

This Photo by Unknown Author is licensed under CC BY-SA

Electronic Nicotine Delivery Systems/Electronic

Battery-powered devices; do not burn or use tobacco leaves;

Nicotine – common drug used

Solutions & emissions contain other chemicals (toxicants)

Electronic Liquid (e-liquid)

Common term for the E-cigarette refill liquid and

Main constituents are:

a) Nicotine (with or without) – active ingredient (THC),

b) Propylene glycol (PEG) or vegetable glycerin (VG) –

• The use of e-cigarettes simulating the experience of

• Use of e-cigarettes; also referred to as “juuling” or

• Process of inhaling the aerosol generated by heating the

Section 1. Definition of Terms

Section 2. Overview of Vaping and E-cigarette

Section 3. Is Vaping for Everyone?

Section 4. Health Risks of Vaping

Section 5. The Pharmacist’s Role in E-cigarette Use

Section 6. Key Takeaway

Section 2 Optional but strongly recommended:

This Photo by Unknown Author is licensed under CC BY-NC-ND

1st documented reference

Herbert A. Gilbert: “smokeless

Image from: https://patents.google.com/patent/US3200819

CASAA. (n.d.) A Historical Timeline of Electronic Cigarettes. Retrieved from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/

The first device in the recent

CASAA. (n.d.). A Historical Timeline of Electronic Cigarettes. Retrieved from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/

The Anatomy of an E-cigarette

E-cigarette devices are composed of:

Photo from E-cigarette, or Vaping, Products Visual Dictionary by the CDC.

These cartridges/pods contain

The anatomy of a Pod-based E-cigarette

1 PHIX pod = 75 mg Nicotine

Different names, same device

Photo from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html

ENDS look like regular

The differences in design and

Resembles USB flash

Quick comparison of traditional vs electronic cigarette

• Works by combustion • Works by convection or