ΗΚΕΙΣΡΟΜΘΙΟ ΣΘΓΑΡΟ. Παρασκεσή Κατσαούνοσ Λέκτορας Πνεσμονολογίας Ιατρική τολή Αθηνών ΓΝ ΕΤΑΓΓΕΛΙΜΟ

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1 ΗΚΕΙΣΡΟΜΘΙΟ ΣΘΓΑΡΟ Παρασκεσή Κατσαούνοσ Λέκτορας Πνεσμονολογίας Ιατρική τολή Αθηνών ΓΝ ΕΤΑΓΓΕΛΙΜΟ

2 ΗΚΕΙΣΡΟΜΘΙΟ ΣΘΓΑΡΟ Η Παγθόζκηα Οξγάλσζε πγείαο έδσζε ζε απηά ηα πξντόληα ηελ νλνκαζία electronic nicotine delivery systems (ENDS). Υξεζηκνπνηνύληαη επίζεο, νη όξνη electronic cigarette, e-cigarette

3 ΗΚΕΙΣΡΟΜΘΙΟ ΣΘΓΑΡΟ Η επηλόεζε ηνπ ήηαλ παηέληα ηνπ Herbert A. Gilbert ην Λόγσ ηεο έιιεηςεο ηερλνινγίαο θαη επεηδή ην tobacco δε ζεσξνύηαλ βιαβεξό ε ζπζθεπή δελ πξνσζήζεθε. Σν ζεκεξηλό ειεθηξνληθό ηζηγάξν είλαη δεκηνπξγία ηνπ θηλέδνπ θαξκαθνπνηνύ Hon Lik, ν νπνίνο ην παξνπζίαζε ην 2003 θαη εκθαλίζηεθε ζηελ αγνξά ηνλ επόκελν ρξόλν. Η εηαηξεία ζηελ νπνία δνύιεπε, νλόκαηη Golden Dragon Holdings άιιαμε ην όλνκα ηεο ζε Ruyan (πνπ ζεκαίλεη παξόκνην κε ην θάπληζκα) θαη άξρηζε λα εμάγεη ηα πξντόληα ην , ελώ θαηνρπξώζεθε ζαλ παγθόζκηα παηέληα ην 2007.

4 ΗΚΕΙΣΡΟΜΘΙΟ ΣΘΓΑΡΟ Μνηάδεη κε ηζηγάξν, αιιά δελ θαίεη θαπλό. Παξάγεη αηκό από έλα ζεξκαληηθό ζηνηρείν πνπ ηξνθνδνηείηαη από κπαηαξία θαη ηνπνζεηνύληαη αληαιιαθηηθά θηαιίδηα. Αλαιόγσο ηε κάξθα ηα αληαιιαθηηθά πεξηέρνπλ ληθνηίλε, πγξνζθνπηθά ζηνηρεία γηα λα παξάγνπλ αηκό (όπσο propylene glycol ή glycerol) θαη γεύζεηο (όπσο θαπλνύ, κέληαο, θξνύησλ, ζνθνιάηαο). Κάπνηεο κάξθεο πεξηέρνπλ θαξκαθεπηηθέο νπζίεο (όπσο rimonabant, amino-tadalafil)

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6 ΗΚΕΙΣΡΟΜΘΙΟ ΣΘΓΑΡΟ Τπνθαζηζηά ηε ληθνηίλε Τπνθαζηζηά ηελ αίζζεζε, ηελ νπηηθή εηθόλα θαη ηε ζπκπεξηθνξά ΩΣΟΟ Τπάξρνπλ ιίγεο πιεξνθνξίεο γηα ηελ αζθάιεηα ηελ απνηειεζκαηηθόηεηα ηελ πηζαλόηεηα θαηάρξεζεο απηώλ ησλ πξντόλησλ

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9 ΥΗΜΙΚΕ ΟΤΙΕ ΑΝΑ ΣΙΓΑΡΟ Acetaldehyde 980 micrograms to 1.37 milligrams Acrylonitrile formerly 1 to 2 milligrams. This product was used as a fumigant in tobacco. Its use has since been discontinued. 4-Aminobiphenyl 0.2 to 23 nanograms per cigarette o-anisidine hydrochloride unknown Arsenic unknown Benzene 5.9 to 75 micrograms Beryllium 0.5 nanograms 1,3-Butadiene 152 to 400 micrograms Cadmium 1.7 micrograms 1,1-Dimethylhydrazine unknown Ethylene oxide unknown Formaldehyde unknown Furan unknown Heterocyclic amines unknown Hydrazine 32 micrograms Isoprene :3.1 milligrams Lead unknown 2-Naphthylamine 1.5 to 35 nanograms Nitromethane unknown N-Nitrosodi-n-butylamine 3 nanograms N- Nitrosodiethanolamine 24 to 36 nanograms N-Nitrosodiethylamine up to 8.3 nanograms N-Nitrosodimethylamine 5.7 to 43 nanograms N-Nitrosodi-npropylamine 1 nanogram 4-(N-Nitrosomethylamino)-1-(3-pyridyl)-1- butanone up to 4.2 micrograms N-Nitrosonornicotine 14 micrograms N- Nitrosopiperidine unknown N-Nitrosopyrrolidine 113 nanograms N- Nitrososarcosine 22 to 460 nanograms Polonium-210 variable, depending on soil and fertilizer used to grow tobacco [2] Polycyclic aromatic hydrocarbons 28 to 100 milligrams o-toluidine 32 nanograms Vinyl chloride 5.6 to 27 nanograms

10 Identification of amino-tadalafil and rimonabant in electronic cigarette products using high pressure liquid chromatography with diode array and tandem mass spectrometric detection Hadwiger ME et al. J Chromatogr A Nov Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Etter JF, Bullen C. Addicton 2011 Nov

11 Ηλεκτρονικό Σσιγάρο Θέση της ERS 2012 Aληηηίζεηαη ζηε ρξήζε όισλ ησλ πξντόλησλ θαπλνύ θαζώο θαη ζηελ πξνώζεζε πξντόλησλ ληθνηίλεο ρσξίο έγθξηζε όπσο ν καζώκελoο θαπλόο, θαη άιια λέα πξντόληα, πνπ πεξηιακβάλνπλ ηα ειεθηξνληθά ηζηγάξα (e-cigs), ην snuss (ζνπεδηθόο ελδνζηνκαηηθό πξντόλ θαπλνύ), ηνλ δηαιπόκελν θαπλό θαη ηνλ λαξγηιέ. Γελ ππάξρεη θακία αμηόπηζηε επηζηεκνληθή κειέηε γηα λα ηεθκεξηώζεη όηη είλαη αζθαιείο ελαιιαθηηθέο ιύζεηο ζηα ζπκβαηηθά ηζηγάξα.

12 Ηλεκτρονικό Σσιγάρο Θέση της ERS 2012 Γηαζέζηκεο έξεπλεο δείρλνπλ όηη ηα πξντόληα απηά ελέρνπλ ζεκαληηθό θίλδπλν γηα ηελ πγεία ησλ θαπληζηώλ. ε έλα πξόζθαην δείγκα ηνπ πξντόληνο δηαπηζηώζεθε όηη πεξηέρεη θαξθηλνγόλεο θαη ηνμηθέο ρεκηθέο νπζίεο όπσο δηαηζπιελνγιπθόιε, έλα ζπζηαηηθό πνπ ρξεζηκνπνηείηαη ζαλ πιηθό απόςπμεο.

13 Ηλεκτρονικό Σσιγάρο Θέση της ERS 2012 Η Δπξσπατθή Πλεπκνλνινγηθή Δηαηξεία δελ ηαμηλνκεί ηα ειεθηξνληθά ηζηγάξα σο αζθαιή ελαιιαθηηθή ιύζε ζην θάπληζκα νύηε ηα ζεσξεί έλα εγθεθξηκέλν εξγαιείν γηα ηελ δηαθνπή ηνπ θαπλίζκαηνο ή θαηάιιεια γηα λα ρξεζηκνπνηνύληαη ζε ρώξνπο όπνπ ην ζπκβαηηθό θάπληζκα απαγνξεύεηαη. Η Δπξσπατθή Πλεπκνλνινγηθή Δηαηξεία ππνζηεξίδεη όηη νη θαπληζηέο "δελ ζα πξέπεη λα αληαιιάζνπλ έλα θαξθηλνγόλν πξντόλ κε έλα άιιν..."

14 ΑΛΕΕ ΕΠΘΔΡΑΕΘ ΣΟ ΑΜΑΠΜΕΤΣΘΙΟ ΛΕΣΑ ΣΗ ΥΡΗΗ ΗΚΕΙΣΡΟΜΘΙΟΤ ΣΘΓΑΡΟΤ Υπήζη ηλεκηπονικού ηζιγάπος για 5 λεπηά με ανηαλλακηικό ζε 30 ςγιείρ μη καπνιζηέρ, ζε ζύγκπιζη με σπήζη σωπίρ ανηαλλακηικό ζε 10 άηομα (ομάδα ελέγσος) Διαπιζηώθηκε μείωζη ηος εκπνεόμενος FeNO και αύξηζη ηων ανηιζηάζεων (Z5Hz, R5Hz, R10Hz, R20Hz) ζηην ομάδα ηος ηλεκηπονικού ηζιγάπος. Short-term Pulmonary Effects of Using an Electronic Cigarette: Impact on Respiratory Flow Resistance, Impedance, and Exhaled Nitric Oxide. C.Vardavas,N.Anagnostopoulos,M.Kougias,V.Evangelopoulou,G.Connolly,P.Behrakis CHEST.2012;141(6):

15 ERS Vienna 2012 : Session: 109 Sunday 2 September, 12:50-14:40 Room: Halle A-29 ACUTE EFFECT OF E-CIGARETTE ON PULMONARY FUNCTION IN HEALTHY SUBJECTS AND IN SMOKERS Gennimata S, Palamidas A, Kaltsakas G, Tsikrika S, Vakali,S, Gratziou Ch and Koulouris N 1st Department of Respiratory Medicine, Medical school, Athens University Sotiria Hospital, Athens

16 AIM This study was set out to investigate the acute effects of e-cigarette use on respiratory functions in healthy subjects and in smokers with and without chronic airway obstruction (patients with COPD and asthma).

17 SUBJECTS Four groups of subjects have been studied: Non-smokers subjects Smokers (with no symptoms & normal spirometry) Smoker patients with COPD Smoker patients with Asthma

18 METHODS Pulmonary function tests have been performed before and after 10min use of e-cig Spirometry (dynamic lung volumes) Body plethysmography(static lung volumes), Airways resistance (Raw, sgaw) DLCO Small airways Function -single-breath nitrogen test,

19 E-cig caused immediate increase in Airway Resistance Airways Resistance before and after 10 min e-cig use in the subject groups

20 CONCLUSIONS The preliminary results of this study have shown that there is an immediate acute effect even of a short term use of an e-cigarette on respiratory system leading in deterioration of airways resistance and airways obstruction. Further studies are needed to establish the long-term effects in healthy subjects and in patients with airways diseases.

21 Sustained 50% reduction in the number of cig/day at week-24 was shown in 13/40(32.5%) participants; Their median of 25 cigs/day decreasing to 6 cigs/day (p < 0.001). Sustained 80% reduction was shown in 5/40(12.5%) participants; their median of 30 cigs/day decreasing to 3 cigs/day (p = 0.043). Sustained smoking abstinence at week-24 was observed in 9/40(22.5%) participants, with 6/9 still using the e-cigarette by the end of the study. Combined sustained 50% reduction and smoking abstinence was shown in 22/40 (55%) participants, with an overall 88% fall in cigs/day. Mouth (20.6%) and throat (32.4%) irritation, and dry cough (32.4%) were common, but diminished substantially by week-24. Overall, 2 to 3 cartridges/day were used throughout the study. Participants' perception and acceptance of the product was good.

22 Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models Vasundhra Bahl et al. Reprod Toxicol 2012 Aug Electronic cigarette refill fluids were examined for cytotoxicity: Embryonic cells were more sensitive to refill fluid than adult lung cells. Flavorings, but not nicotine, were linked to toxicity. Refill products varied from non-cytotoxic to highly cytotoxic. Products from two companies were cytotoxic to embryonic cells but not lung cells.

23 An Unexpected Consequence of Electronic Cigarette Use CHEST 2012; 141( 4 ): A 42-year-old woman was admitted to the hospital with a 7-month history of dyspnea, productive cough, subjective fevers. She had been seen multiple times in the ED with similar complaints and had received several courses of antibiotics. The patient had recently started using electronic cigarettes about 7 months prior which coincided with the onset of her respiratory symptoms. Her past medical history also was significant for asthma, reported rheumatoid arthritis, schizoaffective disorder, and hypertension.

24 ΑΛΛΑ ΝΔΑ... Vietnam veteran suffers horrific burns as electronic cigarette EXPLODES inside his mouth and blows out all of his teeth. Debris flew around room melting all that it touched essentially holding a bottle rocket in his mouth.

25 ΑΛΛΑ ΝΔΑ... M6 terror alert was caused by electronic cigarette

26 ΑΛΛΑ ΝΔΑ... A London based electronic cigarette retailer, is cooperating with the world s largest E-liquid manufacturer, to give out free electronic cigarette kits for smokers in the Olympic games.

27 ΗΜΑΝΣΙΚΟΙ ΠΡΟΒΛΗΜΑΣΙΜΟΙ Ω ΔΠΙΣΗΜΟΝΔ

28 ΙΣΟΡΙΑ ΣΟΤ ΚΑΠΝΟΤ πεξηνρή Yucatan, αλαθαιύθζεθε ζθόλε θύιισλ θαπλνύ ζε αληηθείκελα πνπ ρξνλνινγνύληαη πξν εηώλ π.υ. Αξραία Διιάδα: ρξήζε θαπλνύ από ηελ Ππζία ηνπ Μαληείνπ ησ Γειθώλ Νεζηά Μπαράκαο: αλαθάιπςε από ηνλ Υξηζηόθνξν Κνιόκβν εθηόο απ ηνλ Νέν Κόζκν θαη ηνλ λέν θόζκν ηνπ θαπλνύ. Αξρηθά από ηελ Ιζπαλία εμαπιώζεθε γξήγνξα ζε όιε ηελ Δπξώπε. Rodriguo de Jerez: ν πξώηνο Δπξσπαίνο θαπληζηήο. Η ρξήζε ηνπ θαπλνύ ζεσξήζεθε θαξκαθεπηηθή

29 ΗΜΑΝΣΙΚΟΙ ΠΡΟΒΛΗΜΑΣΙΜΟΙ Ω ΔΠΙΣΗΜΟΝΔ...

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31 ΔΚΣΟΣΔ... Doll R, Hill AB. The mortality of doctors in relation to theirsmoking habits: a preliminary report. BMJ1954; 1: Doll R, Hill AB. Lung cancer and other causes of death inrelation to smoking: a second report on the mortality ofbritish doctors. BMJ1956; 2: Η ζρέζε θαπλίζκαηνο-θαξθίλνπ πλεύκνλα είλαη ε πην θαιά ηεθκεξησκέλε ζρέζε πεξηβαιινληηθνύ παξάγνληα κε αλζξώπηλν όγθν.

32 Ν ΟΜΩ... Παγθόζκηα επηδεκία πνπ έρεη θνξπθσζεί ζηνλ αλεπηπγκέλν θόζκν, αιιά αλακέλεηαη αύμεζε ζηνλ αλαπηπζζόκελν θαη ζηηο γπλαίθεο θαη παηδηά. ΑΕΕ Λοιμώξειρ κατώτεπος Αναπνεςστικού ΥΑΠ Διαπποϊκέρ κενώσειρ HIV/AIDS Φςματίωση Κακοήθειερ πνεύμονα Σποσαία Πποωπότητα 4th rd Δ ΤΠΕΡΣΑΗ ΚΑΡΚΙΝΟ ΣΟΜΑΥΟΤ

33 Η ΕΚΚΑΔΑ ΠΡΧΣΑΘΚΗΣΡΘΑ ΣΟ ΙΑΠΜΘΛΑ

34 Έλαο ζηνπο ηξεηο ζαλάηνπο αλδξώλ κέζεο ειηθίαο νθείιεηαη ζην θάπληζκα Έλληνερ κάθε σπόνο σάνοςν τη ζωή τοςρ εξαιτίαρ τος καπνίσματορ!!! WHO, European HFA-DB, 2006

35 Η ΝΙΚΟΣΙΝΗ ΔΙΝΑΙ ΔΞΑΡΣΗΙΟΓΟΝΟ David Nutt et al. Development of a rational scale to assess the harm of drugs of potential misuse, Lancet, Vol 369 March 24, 2007

36 Η ΝΙΚΟΣΙΝΗ ΔΙΝΑΙ ΔΞΑΡΣΗΙΟΓΟΝΟ Jan van Amsterdam et al, Ranking the Harm of Alcohol, Tobacco and Illicit Drugs for the Individual and the Population, Eur Addict Res 2010;16:

37 ΑΦΑΛΔ;

38 ΠΡΟΣΤΠΑ...

39 ΠΡΟΣΤΠΑ...

40 American Thoracic Society would like to submit comments in support of the FAA s proposed rule to ban these of e cigarettes on commercial flights. As the safety and efficacy of e-cigarettes have not been fully studied, consumers of e-cigarette products currently have no way of knowing: whether e-cigarettes are safe for their intended use, how much nicotine or other potentially harmful chemicals are being inhaled during use, or if there are any benefits associated with using these products. Σα ηλεκηπονικά ηζιγάπα δεν ηαξινομούνηαι ωρ αζθαλή εναλλακηική λύζη ζηο κάπνιζμα ούηε θεωπούνηαι εγκεκπιμένα επγαλεία για ηην διακοπή ηος καπνίζμαηορ ή καηάλληλα για να σπηζιμοποιούνηαι ζε σώποςρ όπος ηο ζςμβαηικό κάπνιζμα απαγοπεύεηαι. Δεν έσει σοπηγηθεί άδεια κςκλοθοπίαρ ζε ανάλογο πποϊόν για ηην Ελληνική αγοπά. Ηλεκηπονικά ηζιγάπα πος δεν πεπιέσοςν νικοηίνη θα ππέπει να εξεηαζηούν από ηο Τποςπγείο Ανάπηςξηρ

41 Electronic Nicotine Delivery Devices (ENDS) In July 2009, the FDA publicly discouraged the use of electronic cigarettes and raised concerns that electronic cigarettes may be marketed to young people and lack appropriate health warnings. American Thoracic Society would like to submit comments in support of the FAA s proposed rule to ban these of e cigarettes on commercial flights Ban for the use of e-cigarettes on trains and in any area where smoking is prohibited

42 In May 2009 the FDA tested 19 varieties of electronic cigarette cartridges produced by two vendors. Diethylene glycol, a poisonous and hygroscopic liquid, was detected in one of the cartridges of one brand.tobacco-specific nitrosamines (TSNAs), known cancercausing agents, were detected in all of the cartridges from one brand and two of the cartridges from the other brand. Nicotine can also be traced in some claimed nicotine-free cartridge. Further concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device. Some cartridges were found to contain "tobacco-specific impurities suspected of being harmful to humans anabasine, myosmine, and β-nicotyrine were detected in a majority of the samples tested."

43 ERS POSITION Because of the concerns that have been raised for these products their use needs to be adequately addressed by Proper evaluation and regulation by the appropriate national and European authorities ΠΡΟΪΟΝΣΑ ΚΑΠΝΟΤ; Οπόηε ζα πξέπεη λα αθνινπζήζνπλ ηελ αλάινγε λνκνζεζία γηα ηνλ θαπλό: - Απαγόξεπζε ζε δεκόζηνπο ρώξνπο - Απαγόξεπζε δηαθήκηζεο - Τςειή θνξνινγία ΦΑΡΜΑΚΟ; Οπόηε ζα πξέπεη λα αθνινπζήζνπλ ηελ αλάινγε λνκνζεζία γηα ηα ηαηξηθά πξνηόλη - Απαγόξεπζε δηαθήκηζεο - Κιηληθέο κειέηεο

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45 ΛΙΓΟΣΔΡΟ ΒΛΑΒΔΡΑ ΣΙΓΑΡΑ Philip Morris International, one of the world s largest tobacco cigarette companies, has announced it will launch a new line of lower health risk cigarettes, sometime in the next four years. Philip Morris International is planning to fight back against the increasingly popular electronic cigarette industry by launching three new prοducts they say will be less harmful for the human body. Σhe most promising of the three lower health risk cigarettes would heat tobacco instead of burning it.

46 ebay's decision to remove all listings and ban the smoking cessation product electronic cigarettes and the refills. Facebook Banning Electronic Cigarette Fanpages Application for e-cig

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48 ΤΜΟΦΘΖΟΜΣΑ Σν ειεθηξνληθό ηζηγάξν δελ έρεη εγθξηζεί από ην FDA σο βνήζεκα γηα ηε δηαθνπή ηνπ θαπλίζκαηνο. Τπάξρεη πιήξεο απαγόξεπζε ηεο ρξήζεο ηνπ ειεθηξνληθνύ ηζηγάξνπ ζε δεκόζηνπο ρώξνπο ζε όιν θαη πεξηζζόηεξεο ρώξεο. Η πξνώζεζε απηνύ ηνπ πξντόληνο κπνξεί λα πεξάζεη ην κήλπκα ζε παηδηά θαη εθήβνπο όηη ην ειεθηξνληθό ηζηγάξν είλαη αθίλδπλν, απμάλνληαο ηνλ θίλδπλνπ εζηζκνύ ζηε ληθνηίλε ζε απηό ηνλ επάισην πιεζπζκό.

49 ΤΜΟΦΘΖΟΜΣΑ Ο αηκόο από ην ειεθηξνληθό ηζηγάξν πεξηέρεη δηάθνξεο ρεκηθέο νπζίεο, όρη κόλν ληθνηίλε. Γελ έρεη δηεπθξηληζηεί εάλ ε εηζπλνή απηώλ ησλ νπζηώλ είλαη αζθαιήο. Γελ έρεη απνδεηρζεί όηη ην ειεθηξνληθό ηζηγάξν βνεζά ηνπο θαπληζηέο λα δηαθόςνπλ ην θάπληζκα. Τπάξρνπλ δηαζέζηκα θαξκαθεπηηθά ζθεπάζκαηα πνπ έρνπλ απνδεηρζεί όηη είλαη αζθαιή θαη απνηειεζκαηηθά γηα ηε δηαθνπή ηνπ θαπλίζκαηνο.

50 αο επραξηζηώ γηα ηελ πξνζνρή ζαο

51 ERS statement on e-cigarettes and emerging products Available at

52 ΑΜΕΕ ΕΠΙΔΡΑΕΙ ΣΟ ΑΝΑΠΝΕΤΣΙΚΟ ΜΕΣΑ ΣΗ ΥΡΗΗ ΗΛΕΚΣΡΟΝΙΚΟΤ ΣΙΓΑΡΟΤ Spirometry, static lung volumes, airway resistance (Raw), airway conductance (sgaw) and a single breath nitrogen test (the slope of phase III; ΓN2/L), were measured in 32 subjects before and after the use of an e- cigarette smoked for 10 minutes. Immediately after smoking an e-cigarette for 10 minutes there was: a) a statistically significant increase in Raw %pred (from 223±80 to 246±86, p=0.008) b) a statistically significant decrease in sgaw %pred (from 46±20 to 41±17, p=0.005), and c) a statistically significant increase in ΓΝ2/L %pred (from 146±100 to 164±121, p=0.002). S.A. Genimata, et al ERS, 2012

53 ΑΛΕΕ ΕΠΘΔΡΑΕΘ ΣΟ ΑΜΑΠΜΕΤΣΘΙΟ ΛΕΣΑ ΣΗ ΥΡΗΗ ΗΚΕΙΣΡΟΜΘΙΟΤ ΣΘΓΑΡΟΤ After smoking a single e-cigarette for 10 minutes, the group (37 subjects) reported cough (65%), sore throat (68%), irritation in eyes (24%), difference in taste (78%), dizziness (24%) and feeling of satisfaction (51%). In addition, there was a statistically significant: a) increase in HR (from 75±10 to 92±17, p<0,001), b) increase in eco (from 13±12 to 15±9, p=0,03), and c) a decrease in SpO2 (from 97,46±2 to 96,76±1, p=0,012) after smoking. S. Vakali, et al ERS, 2012

54 A COPD patient s curve of SBN2T pre and post the e-cigarette smoking. A: pre. B: post (N2:blue line) Mean values of Raw %pred and the difference pre and post an e-cigarette in all groups. ACUTE EFFECT OF E-CIGARETTE ON PULMONARY FUNCTION IN HEALTHY SUBJECTS AND SMOKERS S. Gennimata, A.Palamidas, G.Kaltsakas, S.Tsikrika, S.Vakali, C. Gratziou and N. Koulouris ERS Vienna 2012

55 Short-term Pulmonary Effects of Using an Electronic Cigarette: Impact on Respiratory Flow Resistance, Impedance, and Exhaled Nitric Oxide C.Vardavas,N.Anagnostopoulos,M.Kougias,V.Evangelopoulou,G.Connolly,P.Behrakis CHEST.2012;141(6):

56 Does e-cigarette consumption cause passive vaping? T. Schripp, D. Markewitz, E. Uhde,T. Salthammer Indoor Air 2012;