E-Cigarettes: What Are They and Are They Safe?

Introduction 

Technology has been advancing in recent years, leading to massive development in various sectors of the economy. Even though technological development is recognized for enhancing social and economic development, some consequences have come alongside technological growth (Schot and Steinmueller, 2018). In modern society, various innovations have been incorporated into substance use. Electronic-cigarettes is one of the significant emerging controversy in substance use, particularly the use of tobacco. Electronic cigarettes, commonly known as e-cigarettes, have been on the rise over recent years and have continued to become more relevant among cigarette smokers, especially adolescents. The younger generation perceives e-cigarettes as some fashion, so most adolescents turn to e-cigarettes compared to traditional cigarettes. 

There has been a controversial global debate between the manufacturers of e-cigarettes and antismoking advocates over e-cigarettes. Antismoking advocates believe that e-cigarettes are causing more harm than and, therefore, should be prohibited. The use of e-cigarettes is raising severe health issues among its users. In addition to that, there are ethical and cultural issues that have also been associated with the use of e-cigarettes. Electronic cigarettes have also raised serious ethical, legal, and practical dilemmas for various stakeholders, including individuals affected by the product (Notley et al., 2018). The government regulators have been at the forefront in protecting the e-cigarettes users against exploitation by the manufactures. Besides, the employers and medical community are pushing for the prohibition of e-cigarettes owing to its massive negative impact. 

In some instances, e-cigarettes have been regarded as "evil weed" because they contain some weed elements. The nicotine factor in e-cigarettes makes it more enticing to people, especially adolescents, where the number of users has increased significantly. E-cigarette users believe that it gets them more "high" and much more potent than other tobacco products. There are also claims that e-cigarettes have low nicotine content and should be regarded as beneficial and suitable for use; they can act as cessation devices or function as a smoking reduction (Worku and Worku, 2019). Despite the heated discussion concerning the use of e-cigarettes, no scientific deal has been made on whether e-cigarettes cause harm or benefits to its users. However, numerous past points towards the direction that e-cigarettes could be causing significant damage to its users and going against society's moral and ethical provision. This research paper presents a fair and balanced discussion concerning the use of e-cigarettes. 

Research Questions 

What are the statistical facts related to this issue? 

What are the long-term effects E-cigarettes have on adolescents? 

What effects does E-cigarettes have on the body? 

What laws govern or pertain to the issue? 

Which cultural values and norms influence the issue? 

Statistical Facts Related to E-Cigarettes 

According to Wang et al. (2019), E-cigarettes refer to battery-powered tubes that transform nicotine-laced into vapor in steam form; the user then inhales the smoke. The e-cigarettes vapor is commonly referred to as "Vaping," a word used to refer to non-smoking e-cigarettes proponents. When exhaling e-cigarettes, a thin cloud that quickly fades out is produced. Even though some people feel good when inhaling traditional cigarettes, the feeling is very unpleasant to the majority because it is associated with nausea and coughing. However, in the case of e-cigarettes, the sensation of inhalation is excellent. The majority love it; this is why the majority prefer e-cigarettes compared to inhaling traditional cigarettes. Besides the superb feeling, e-cigarettes have nicotine and other compounds that are generally considered safe for use. Glycerine and propylene is an example of such compounds (Barton et al., 2020). The manufacturers and users of e-cigarettes have defended its use because it contains components that are as safe and harmful. For instance, propylene glycol, one of the main ingredients, has been used in many elements and has never been detrimental to human health. Even as e-cigarettes users and manufacturers continue to praise and defend this tobacco product, some employers and government have continued to raise concern over the use of e-cigarettes, citing the consequences of using the product. Employers always want their employees to remain and mentally and physically healthy, and therefore anything that affects their health raises serious health concerns. 

Typically, an e-cigarette is made up of a metal tube with a battery, an atomizer, and a cartridge, mainly filled with nicotine's liquid solution. It also has a battery that powers coils, thus heating liquid nicotine solution into a vapor. When e-cigarettes are sucked, the diode emitting light causes the tip to glow. The atomizer subsequently turns the liquid nicotine to vapor for inhalation by the user. In most cases, the end glows in blue, but it lights in red in other cases. The e-cigarettes user inhales the vapor and exhales vapor in smoke (Dautzenberg and Garelik, 2017). E-cigarettes have different definitions depending on the perception. The U.S. Federal Drug Administration defines e-cigarettes as battery-operated products intended to deliver flavor, nicotine, and other chemicals. 

In most cases, e-cigarettes are manufactured to appear like conventional pipes, cigarettes, and cigars. In some situations, the cigarettes resemble USB memory sticks and pens. The toxicity of e-cigarettes usually varies depending on the nicotine strengths; nicotine solutions' strength is varied with the brand. Generally, the e-cigarettes product comprises three components: batteries, a set of nicotine cartridges, and the e-cigarettes device. The e-cigarettes product costs an average of $90 typically. 

Different manufacturing companies in the United States produce e-cigarettes. Lorillard Tobacco Company is the primary producer of e-cigarettes brands in the United States. The company which has Newport and Kent traditional cigarettes makes an e-cigarettes brand known as Blu. The brand looks like a pack of cigarettes, and it comes with a charger. The blu starter packs have five nicotine cartridges and two batteries. The group lasts for approximately 150 puffs in every piece. In a decade, e-cigarettes companies have grown significantly, with distribution stores spreading across the nations (Hsu and Grodal, 2020). E-cigarettes generally require a more significant investment as compared to traditional cigarettes. However, with the increasing demands of e-cigarettes, the industry has been increasing, with projections that it could overtake conventional cigarette brands. E-cigarettes usually require more massive financial investment because it has rechargeable kits, but in the long run, the brand might be less expensive than a regular brand. Besides, some brands of e-cigarettes are disposable, thus having nearly similar prices range with traditional cigarette brands. Like conventional cigarettes, e-cigarettes have warning labels that contain nicotine that can be addictive in the long run. Unlike regular cigarettes, e-cigarettes do not contain arsenic, tars, and other cancerous chemicals; therefore, they only warm their users against addictions and not cancer. Despite the claim that e-cigarettes are non-cancerous, the product has numerous side effects, including vomiting, nausea, and skin irritation. A recent study indicates that e-cigarettes have multiple side effects, but these consequences are much smaller than traditional cigarettes' health effects (Polosa et al., 2017). 

Effects E-Cigarettes Have on Adolescents. 

The use of cigarettes among adolescents has been on the rise over the past decade; many adolescents have turned to cigarette smoking and other substance abuse. Sources indicate that the introduction of e-cigarettes has fueled the use of cigarettes among the adolescent. The use of e-cigarettes among youths is attributed to their flavors and the social status associated with their users. Some of the flavors of e-cigarettes include candy, mint, fruit, and methanol. A study conducted between 2013 and 2014 indicates that most adolescents who use e-cigarettes begin with flavored variety. The study further shows that the primary reason why adolescents use e-cigarettes is because of its flavors. Another 2020 report has shown that most users who use e-cigarettes preferred flavored verities; about 82.9 percent (Goldenson, 2018). The vigorous advertisement of e-cigarettes by its manufacturers was pushing many adolescents to use the product. 

Furthermore, many adolescents are using e-cigarettes because of their curiosity about the product. As e-cigarettes among the youths continue to rise, government regulators are doing all it takes to control their use. Various enforcement policies are being put in place to prohibit the sales of e-cigarettes among adolescents. Several communities and states have restricted the sales of flavored tobacco to control e-cigarettes among adolescents. The use of e-cigarettes among adolescents may have both short-term and long-term effects. The effects of e-cigarettes use among adolescents are as follows: 

Brain Risks: The brain part responsible for impulse control and decision making among adolescents is not dully developed. Therefore, young people are more likely to take high health and safety risks when using nicotine and other drugs. Adolescents and young adults are at high risk of developing long-term complications, including mood disorders, nicotine addiction, and permanent lowering of impulse control. Furthermore, nicotine can harm a part of the brain by changing how synapses are formed. 

Addiction: The brain grows until the age of 25. Every time a new memory is created, stronger synapses and connections are built between brain cells. The brains of young people make synapses faster than the adult brain. Therefore, they can easily get addicted faster than how adults would be addicted; this is because addiction is information about learning. The nicotine in e-cigarettes can prime adolescents' brains for addiction to other substance use such as cocaine. 

Behavioral Risk: The use of e-cigarettes among adolescents is strongly connected to e-cigarette products like cigars, regular cigarettes, and hookah. Past research has shown that the use of e-cigarettes has been associated with alcohol use and other drugs such as marijuana (Mehra et al., 2019). There are e-cigarette products that can also be used in delivering other substance use like tobacco. 

Effects of E-Cigarettes Have on the Body 

Since the introduction of e-cigarettes, numerous versions have been produced, with some brands being exactly looking the same as that of traditional cigarettes. These types of e-cigarettes have a glowing tip and sleek shape similar to that of regular tobacco. However, no tobacco is neither released nor burned; this distinguishes these e-cigarettes from the traditional brands. According to a study conducted by the Federal Drug Administration (FDA), about 50 percent of e-cigarettes brands contain carcinogens in regular cigarettes, raising serious health concerns (Sapru et al., 2020). Further study indicated that the e-cigarettes products are highly addictive and have biochemical effects on the user's brain and body. The side effects of e-cigarettes are more intense for pregnant women and young people (Breit et al., 2020). E-cigarettes contain nicotine, a vasoconstrictor narrowing blood vessels, and high pressure among its users, despite numerous studies indicating that e-cigarettes could cause no backed-up evidence showing that e-cigarettes can cause cancers. According to an article in the American weekly business magazine known Bloomberg Businessweek, e-cigarettes are much safer than traditional cigarettes based on the available evidence among the users; the product is less toxic (Cerchiello and Nicola, 2018). 

According to Leigh and Goniewicz (2020), the concentration of e-cigarettes' toxicity depends on the device and brand used. Still, it should be noted that all cigarettes contain nicotine, flavorings, tetrahydrocannabinol (THC), and other chemicals that might be harmful to human health. There are high speculations that e-cigarettes could have high long health risks, but no intense research has been done to validate such claims. As of 2019, approximately 800 cases of severe lung diseases and 12 deaths had been reported in the United States. It was reported that the affected patients had previously used e-cigarettes in one way or the other. 

Nevertheless, the report did not provide evidence of whether the patient has succumbed to vaping devices and e-liquid or device used. Another report produced by the United States Centers for Disease Control and Prevention shows that most patients suffering from lung diseases reported having used products containing tetrahydrocannabinol. Furthermore, several other patients had reported using nicotine, and some even reported using nicotine-containing e-cigarettes. Because no single substance or product has been linked to these diseases, The CDC and FDA have associated the illness with e-cigarettes and urge people to stop using the products. In continued usage cases, the Center for Diseases Control and Prevention recommends that they not be purchased off time, or the cartridges should be modified. Additionally, the CDC recommends that e-cigarettes users should monitor their health very closely. 

Laws Governing E-cigarettes 

The heated debate between government regulators and e-cigarettes manufactures have escalated several legal issues. The regulators have raised several legal regarding the usage of e-cigarettes, notably its health effects and ethical issues. Federal statutory and regulatory laws have been put in place by government agencies to control the use of e-cigarettes and protect the users against exploitation by e-cigarettes manufacturers. 

Even though the current federal statutory organ does not provide for regulations of e-cigarettes, some laws ban the sales and usage of regular cigarettes among minors in the U.S. FDA is the critical government organ that is mandated to control substance use. The regulatory agency has the authority to regulate e-cigarettes, given that it is a tobacco product. In 2014, the FDA's Center for Tobacco Products launched a rulemaking process using e-cigarettes (Sutfin et al., 2018). Before then, the regulatory agency was not considering e-cigarettes as tobacco. Therefore, no regulations were controlling the use of e-cigarettes. But once the FDA rule became law, the service and sales of e-cigarettes became legal according to federal statutes. The FDA rules limited the sales of e-cigarettes, particularly among minors. 

Concerns have been raised over the use of e-cigarettes among minors, with over a million adolescents estimated using the product. The rising political pressure over the use and sales of e-cigarettes has prompted the need to review the FDA's stand on e-cigarettes; the agency has been pressured to act on the issue without further delay. One of the big problems concerning e-cigarettes sales is an aggressive marketing campaign that is mainly targeting minors. Other relevant government agencies like Occupation Safety and Health Administration have also made some proposals that have suggested a smoking ban in millions of workplaces across the nation. 

The FDA is taking the use and sales of e-cigarettes seriously; it has taken several measures to warn people again about using e-cigarettes. On their websites, the FDA is warning consumers against the use of e-cigarettes citing that no proper study has been conducted on its health risks, especially the nicotine component and other chemicals present in the e-cigarettes. In addition to that, the agency is urging e-cigarettes users to report any adverse effects of using the product. According to CNN.com, e-cigarettes provisions are still under review at the White House Office of Management and Budget. Even though there is no regulation regarding the sales of e-cigarettes, pressure continues to pile on the FDA to regulate sales of e-cigarettes. 

Ethical theories that apply to the use of e-cigarettes 

Several cultural and ethical issues have been associated with the sales and use of e-cigarettes. Although manufacturers believe that e-cigarettes are much safer than traditional cigarettes and should be given a second thought, people have raised severe concern about the sales of e-cigarettes to minors. Study indicates that some adolescents have been addicted to using the product, which has affected their physical health. Furthermore, some school dropout cases have been associated with addiction to e-cigarettes (Barton et al., 2020. But the big question is whether the minor should be denied the chance to use e-cigarettes or not. 

Given that most minors using e-cigarettes are interested in it, it is ethical to go against their self-interest in the name of protecting their future. E-cigarettes are associated with moral and cultural issues due to societal problems resulting from the sales and use of e-cigarettes. Some ethical principles and theories can be used to make a moral conclusion regarding e-cigarettes. Some of the ethical theories associated with e-cigarettes include Ethical Egoism, Utilitarianism, and Ethical Relativism. 

Ethical Egoism asserts that a person should promote the most outstanding balance of oneself and self-interest. There is a moral obligation to encourage an individual's self-interest, and there selfishly acing perceived as moral action and actions against one's self-interest is considered an immoral act (Friedland and Cole, 2019). There numerous ethical questions surrounding the use and sales of e-cigarettes. Whether the employers should allow clients, customers, and employees within the business premises, based on an egoistic perspective, the decision to handle the users of e-cigarettes should largely depend on the "pros" and "cons" of the affected party; the egoistic self-interest of the employer. In this case, employers interested is likely to be profits-oriented. Employers should be aware of state laws guarding smoking and make the right decision, considering business interests. Ethical Relativism theory denies that there are moral rules that apply to all societies, all people at all times. Therefore, there is no morals standard to define whether an action is wrong or right; everything depends on an individual, society, and wartime. From an ethical realist point of view, using e-cigarettes will largely depend on the individual using the cigarettes, the time of usage, and the society where it is used. When society accepts the product and is used simultaneously with an interested individual, the use is ethical. The problem is meeting all the factors simultaneously. 

Another ethical theory that applies to e-cigarettes is Utilitarianism; Utilitarianism is one of the popular moral ideas widely used in the Western world. The theory created by Jeremy Bentham and John Stewart Mill has been applied in various ethical dilemmas to determine the morality of an action in society. Utilitarianism is used to determine an activity that is regarded as right from an act that is considered wrong based on the outcome; it implies that theory focuses on the result of the action, whether it is right or wrong (Scarre, 2020). According to Utilitarianism, the most ethical action is the one whose outcome produces the greatest good for the highest number. Based on Utilitarianism, e-cigarettes can be regarded as unethical because it is not good; the outcome of smoking e-cigarettes is the increasing number of school dropouts among adolescents, addictions, and physical and mental health conditions. These outcomes are not for good; therefore, e-cigarettes are regarded as immoral and unethical in society. 

Cultures and societies that are most affected by e-cigarettes 

Besides the physical and mental health effects of e-cigarettes, it is important to consider the cultures or societies most affected by e-cigarettes. To control the use of e-cigarettes in society, the government regulators and other concerned parties should first identify the most affected people in the communities and come up with strategies to control e-cigarettes usage among these groups. In determining the affected group, it is vital to incorporate morality, whether e-cigarettes are moral in society or not. Some various cultures and communities have been affected by e-cigarettes; as discussed below, 

currently, there are hundreds of millions of people across the world who are smoking cigarettes. The study indicates that the United States alone has more than 4o million people who are presently smoking. The number is expected to go upwards with the introduction of e-cigarettes. The study has further indicated that smoking is one of the leading causes of death in the United States, even though it is preventable. As stated earlier, there are massive consequences of e-cigarettes. The majority of e-cigarettes smokers have addicted to drugs; they would always want to smoke again and again 

As far as e-cigarettes are concerned, minors are the most affected group in society. Both the government regulators and non-governmental organizations are worried about the increasing number of children currently using e-cigarettes. The sales and use of e-cigarettes have been banned by both the local and states governments. Even though most minors cannot raise the money to purchase e-cigarettes, a more significant number has been found to use e-cigarettes, thus shifting blame to those who are giving these minors the money to buy the cigarettes. Research has indicated that youths are the most affected group in society (Cox, 2020). Therefore, more effort should be put into controlling the use of e-cigarettes among the young population. 

Even though no proper investigation has been done on the racial use of e-cigarettes, a study has indicated that e-cigarettes are loved by young population of all ethnic and racial backgrounds. There is no restriction on the use of e-cigarettes regarding ethnic and racial lines. The younger population who love e-cigarettes included people with families with young children. Besides the racial and ethnic aspect, research has indicated that e-cigarettes are more loved by the men population than the women population (Teenagers who try e-cigarettes more likely to smoke tobacco," 2016). Regardless of whether it was e-cigarettes or just regular cigarettes, studies have indicated that men are generally prone to smoking than women. 

For the last two decades, e-cigarettes companies have increased significantly, spreading in different parts of the world. The first-ever successful e-cigarettes company was established in Beijing, China, in the year 2003. The company was created by Hon Lik, an inventor, a pharmacist, and a smoker. Hon Lik invented the product after his father, a heavy smoker, died of lung cancer due to smoking (Sapru et al., 2020). There are currently several e-cigarettes companies in the United States, with Reynolds, Altria, and Lorillard as the leading companies in the U.S. Based on the region, China is the top country with the highest number of e-cigarettes smokers. The high number of e-cigarettes smokers in China has been associated with the fact that e-cigarettes originated from China (Danesi, 2018). Other countries closely following China in e-cigarettes smoking include Andorra, Belarus, and Luxembourg. 

Conclusion 

The use and sales of e-cigarettes have sparked mixed reactions and heated debate between manufacturers and government regulators. An E-cigarette is made up of a metal tube with a battery, an atomizer, and a cartridge, mainly filled with a liquid nicotine solution. Based on its component, e-cigarette consists of nicotine and other chemicals that are believed to be harmful to human health. There no conclusive health report regarding the effect of e-cigarettes among its users. However, the study shows that some lung cancer cases and even death have been reported among e-cigarettes users, raising the alarm over the possibility of the product causing lung cancer (Kasza et al., 2017). Despite a lack of assurance on whether e-cigarettes can cause cancer, medical experts and government regulators have continued to warn people against the excessive use of e-cigarettes, especially the product sold by unauthorized dealers. The use of e-cigarettes among minors has also drawn much attention as the number has continued to grow. The government has piled pressure on the FDA to issue e-cigarettes among adolescents, mainly aggressive marketing to minors. Although the current federal statutory organ does not provide for e-cigarettes regulations, some laws ban regular cigarettes sales and usage among adolescents in the United States. FDA is the critical government organ mandated to control substance use -controversies surrounding e-cigarettes. In conclusion, the use of e-cigarettes among the adolescent has both physical and mental health complications. Therefore, the government should consider banning the sales and use of cigarettes among adolescents. 

References 

Barton, B. R., Spicer, K., & Byrd, T. (2020). E-Cigarettes in the Workplace: The Impact on Company Alcohol & Drug Policies.  Professional Safety ,  65 (09), 24-31. 

Barton, B. R., Spicer, K., & Byrd, T. (2020). E-Cigarettes in the Workplace: The Impact on Company Alcohol & Drug Policies.  Professional Safety ,  65 (09), 24-31. 

Breit, K. R., Rodriguez, C., Lei, A., & Thomas, J. D. (2020). Combined vapor exposure to THC and alcohol in pregnant rats: Maternal outcomes and pharmacokinetic effects.  Neurotoxicology and Teratology , 106930. 

Cerchiello, P., & Nicola, G. (2018). Assessing news contagion in finance.  Econometrics ,  6 (1), 5. 

Cox, S. (2020). Dual use of electronic cigarettes and cigarettes.  Definitions . doi:10.32388/mvlsbo 

Danesi, M. (2018). Cigarettes and High Heels: The Universe of Signs.  Of Cigarettes, High Heels, and Other Interesting Things , 1-23. doi:10.1057/978-1-349-95348-6_1 

Dautzenberg, B., & Garelik, D. (2017). Patients with lung cancer: are electronic cigarettes harmful or useful?.  Lung Cancer ,  105 , 42-48. 

Friedland, J., & Cole, B. M. (2019). From Homo-Economicus to Homo-Virtus: A system-theoretic model for raising moral self-awareness.  Journal of Business Ethics ,  155 (1), 191-205. 

Goldenson, N. I. (2018).  Effects of Flavorings in Electronic Cigarettes on the Use and Appeal of E-Cigarettes Among Youth and Adults  (Doctoral dissertation, University of Southern California). 

Hsu, G., & Grodal, S. (2020). The Double-edged Sword of Oppositional Category Positioning: A Study of the U.S. E-cigarette Category, 2007–2017.  Administrative Science Quarterly , 0001839220914855. 

Jong, T., & Ormaechea, L. (2018). Trends to Note in Alcoholic Beverage Trademark Law That Can Impact the Decision Making Process for Businesses at Critical Points in the Alcoholic Beverage Product Life Cycle.  Buff. Intell. Prop. L.J. ,  12 , 19. 

Kasza, K. A., Ambrose, B. K., Conway, K. P., Borek, N., Taylor, K., Goniewicz, M. L., ... & Kaufman, A. R. (2017). Tobacco-product use by adults and youths in the United States in 2013 and 2014.  New England Journal of Medicine ,  376 (4), 342-353. 

Leigh, N. J., & Goniewicz, M. L. (2020). Acute Effect of Electronic Cigarette-Generated Aerosol From Flavored CBD-Containing Refill Solutions on Human Bronchial Epithelial Cells.  Frontiers in Physiology ,  11 , 1312. 

Mehra, V. M., Keethakumar, A., Bohr, Y. M., Abdullah, P., & Tamim, H. (2019). The association between alcohol, marijuana, illegal drug use and current use of E-cigarette among youth and young adults in Canada: results from Canadian Tobacco, Alcohol and Drugs Survey 2017. BMC public health, 19(1), 1208. 

Notley, C., Ward, E., Dawkins, L., & Holland, R. (2018). The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention.  Harm reduction journal ,  15 (1), 1-12. 

Polosa, R., Cibella, F., Caponnetto, P., Maglia, M., Prosperini, U., Russo, C., & Tashkin, D. (2017). Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked.  Scientific reports ,  7 (1), 1-9. 

Sapru, S., Vardhan, M., Li, Q., Guo, Y., Li, X., & Saxena, D. (2020). E-cigarettes use in the United States: reasons for use, perceptions, and effects on health.  BMC Public Health ,  20 (1), 1-10. 

Sapru, S., Vardhan, M., Li, Q., Guo, Y., Li, X., & Saxena, D. (2020). E-cigarettes use in the United States: reasons for use, perceptions, and effects on health.  BMC Public Health ,  20 (1), 1-10. 

Scarre, G. H. (2020). Utilitarianism and Enlightenment.  Utilitarianism , 48-81. doi:10.4324/9781003070962-3 

Schot, J., & Steinmueller, W. E. (2018). Three frames for innovation policy: R&D, systems of innovation and transformative change.  Research Policy ,  47 (9), 1554-1567. 

Sutfin, E. L., Soule, E. K., McKelvey, K., & Jenson, D. (2018). Implications and challenges for implementation of the FDA's final deeming rule for waterpipe tobacco.  Tobacco control ,  27 (3), 347-351. 

Teenagers who try e-cigarettes more likely to smoke tobacco. (2016).  The Pharmaceutical Journal . doi:10.1211/pj.2016.20200557 

Wang, T. W., Gentzke, A. S., Creamer, M. R., Cullen, K. A., Holder-Hayes, E., Sawdey, M. D., ... & Jamal, A. (2019). Tobacco product use and associated factors among middle and high school students—United States, 2019.  MMWR Surveillance Summaries ,  68 (12), 1. 

Worku, D., & Worku, E. (2019). A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool.  SAGE open medicine ,  7 , 2050312119871405.