January 13, 2015

Stanton A. Glantz, PhD

Analysis of "Smoking Ordinances and Electronic Cigarettes" which is used to oppose including ecigs in clean indoor air laws

In December 2014, the Shasta California County Board of Supervisors moved to amend its smokefree law to add e-cigarettes to the list of covered tobacco products. Prior to the public hearing on Tuesday, December 16, a member of Nor Cal Vape sent the Board of Supervisors a report entitled Smoking Ordinances and Electronic Cigarettes prepared by Wisconsin Smoke-Free Alternatives Coalition with help from the e-cigarette advocacy group Consumer Advocates for Smoke-free Alternatives Association (CASAA) arguing against including e-cigarettes in the county’s ordinance.
The Board unanimously voted (5-0) to amend its comprehensive clean indoor air ordinance to include electronic cigarettes.
Since the arguments in this booklet are likely to appear elsewhere, Rachel Barry, a member of my research team, and I have prepared an analysis of the claims it makes.
"Most of the information provided to lawmakers is from special interests that have a clear agenda against tobacco harm reduction policies."
Whether or not e-cigarettes end up having the effect of reducing the damage that smoking does (assertions that have yet to be demonstrated) has nothing to do with whether they are used indoors where bystanders are exposed to the secondhand nicotine, ultrafine particles, and other toxins that e-cigarette users exhale.  Having spent decades cleaning up indoor air, there is no reason to pollute it again
Even if one accepts the argument that e-cigarette users are using them in place of dirtier cigarettes, these people could not smoke and expose themselves to the nicotine and other toxins in cigarettes in smokefree environments.  Allowing e-cigarette use would, therefore, result in an increase in total exposure to nicotine and other toxins in e-cigarette users (compared to smoking nothing).
"Special interests [pressing to include e-cigarettes in clean indoor air laws] that have … financial ties to industries that sell products that are in direct competition with e-cigarettes."
This is certainly not true for us or the nonsmokers’ rights advocates we know.
The irony in this claim, of course, is that the major cigarette companies, Philip Morris, RJ Reynolds, Lorillard, and BAT, have either purchased or started manufacturing their own e-cigarette brands beginning in 2013 and accelerating in 2014.  As of December 2014, the major cigarette manufacturers owned about half of the e-cigarette market.
"An e-cigarette is a smoke-free device used almost exclusively as an alternative to smoking."
The dominant pattern among adults is “dual use” of cigarettes and e-cigarettes, i.e., most smokers continue smoking while using e-cigarettes, but 32.5% of current e-cigarette users were never or former smokers.
Use of e-cigarettes among never-smoking adolescents is increasing rapidly, much more rapidly than among adults, particularly among middle and high school students with relatively low susceptibility to smoking cigarettes.  The CDC found that "Never-smokers who had ever used e-cigarettes were nearly twice as likely to have an intention to smoke conventional cigarettes than never smokers who had not used e-cigarettes" indicating that e-cigarettes may serve as a gateway to conventional cigarettes and not as alternatives to smoking. The University of Michigan’s 2014 Monitoring the Future national survey found that in 2014 "teen use of e-cigarettes surpasse[d] use of tobacco cigarettes" and that "e-cigarettes are a primary source of nicotine and not a supplement to tobacco cigarette use."
Likewise, the California Department of Education > found that lifetime and current use of e-cigarettes surpassed cigarette use among 7th, 9th, and 11th graders in the 2013/14 school year.  Current e-cigarette use was three times higher than current cigarette use for 7th (6.3% vs. 2%) and 9th (12.4% vs. 4.3%) graders, and almost double for 11th graders (14.3% vs. 6.8%). For lifetime use, e-cigarette use was three times higher than cigarette use for 7th graders (2.9% vs. 11.4%), more than two times higher for 9th graders (10.4% vs. 23.6%), and almost two times higher for 11th graders (17.4% vs. 29.3%).
E-cigarettes are very low risk compared to smoking, estimated to pose in the neighborhood of 1/100th the risk.
The reality is that no one knows the long-term risks of e-cigarette use.  While they do expose users to lower levels of many cancer-causing chemicals, they still expose them to nicotine, ultrafine particles, and other toxins that cause heart and non-cancer lung disease.
The fact is, however, that the relative risks to users of e-cigarettes and cigarettes are irrelevant to discussions of clean indoor air laws, where the question is whether or not e-cigarette use increases bystanders’ exposure to exhaled toxins above what it would be if no one was using e-cigarettes in the room. 
“Some opponents of e-cigarettes have made an analogy of the harm reduction potential of e-cigarettes compared to smoking as ‘jumping out of the 15th story instead of the 100th story of a building.’”
As noted above, the harm reduction issue is irrelevant to whether or not e-cigarettes should be included in clean indoor air laws.
“Most smoke-free tobacco/nicotine products, including smokeless tobacco, e-cigarettes, and NRT (pharmaceutical nicotine) are roughly 99% less harmful than smoking.”
As noted above, the harm reduction issue is irrelevant to whether or not e-cigarettes should be included in clean indoor air laws.
“Nicotine is not a carcinogen. It is the carcinogens and toxins in smoke that increase the risk of smoking-related diseases, not the nicotine.”
Although the CDC reports that evidence on whether nicotine as a carcinogen is inconclusive, cancer is not the largest smoking-related cause of death. Smoking-induced heart and metabolic disease and non-cancer lung disease resulted in more deaths than smoking-induced cancer between 1965 and 2014.
The Surgeon General has reported that nicotine is not harmless; it affects the nervous and cardiovascular systems and has adverse effects on fetal growth and development. 
“A recent spate of news reports about calls to poison control centers regarding e-cigarettes do not specify whether the call was an actual poisoning situation or simply informational inquiries.”
E-cigarette related calls to the poison control centers dramatically increased between 2010 and 2014 due to children under five (51.1%) and people age 20 and over (42.2%) ingesting the e-liquid, inhaling or absorbing e-cigarette emissions through the skin or eyes. Most calls reported an adverse affect following exposure including vomiting, nausea, and eye irritation.
“Nicotine levels in e-cigarette vapor are too low to be toxic.”
The level of nicotine delivered in e-cigarettes is designed to support nicotine addiction.
“Vapor does not travel as far from the consumer as smoke and it dissipates quickly.”
Bystanders living with e-cigarette users have similar levels of cotinine – a biomarker of absorbed nicotine – as people living with cigarette smokers.  Similar results were found in a controlled experiment, together with effects on lung function of bystanders.
“The smell of vapor doesn’t settle on people and objects.”
E-cigarettes can produce higher levels of thirdhand nicotine exposure than conventional cigarettes. 
“A Marlboro cigarette has over 11,000 ng/g of tobacco specific carcinogens. E-cigarettes and pharmaceutical nicotine patches both have around 8 ng/g.”
As noted above, cigarettes (and e-cigarettes) have adverse health effects other than cancer.  More important, this point is irrelevant to whether or not e-cigarettes should be included in clean indoor air laws. 
“Reports of finding formaldehyde and other chemicals in e-cigarette vapor fail to disclose that the levels found (0.013 ppm), on average, are lower than can be detected in average city indoor/outdoor air (0.03 ppm).”
Whether or not this is true, this is irrelevant.  The fact is that e-cigarettes emit toxins into the indoor air that would not be there absent the presence of e-cigarettes.
Not surprisingly, the cigarette companies along with their smokers' rights groups made similar claims about cigarette smoke in arguing against clean indoor air laws since the 1980s (example 1example 2 example 3, example 4).  The reality was that levels of respirable suspended particulates (RSP) were substantially higher in places where tobacco was smoked compared to smokefree environments, including outdoors and around vehicles on busy commuter highways.  The same is true for casinos today.
“A comprehensive study done in 2013 by Dr. Igor Burstyn (Drexel University School of Public Health) reviewed all available e-cigarette chemical tests and found that chemicals in e-cigarettes pose no health concern for users or bystanders based on generally accepted exposure limits.”
The Burstyn study, funded by the CASAA, used an inappropriate standard to estimate the risk associated with secondhand smoke exposure to cigarette aerosol. The Threshold Limit Values (TLVs) Burstyn used in his analysis were developed for workers in occupational settings and do not represent public health standard values.
The tobacco industry promoted similar misleading studies using permissible exposure levels (PELs which are similar to TLVs) on chemicals found in secondhand smoke in the 1980s (example 1, example 2) and subsequently used these studies to argue that ventilation systems would effectively reduce the level of toxic chemicals in secondhand smoke to oppose clean indoor air legislation (example 1, example 2, example 3).
A paper published in the June 2014 issue of ASHRAE Journal which uses appropriate standards provides strong evidence for policymakers to include e-cigarettes in smokefree laws.  It notes that e-cigarette aerosol contains carcinogenic chemicals including formaldehyde, metals (cadmium, lead, nickel), and nitrosamines and that indirect exposure poses a significant health risk to bystanders and concludes "ventilation is not a solution and e-cigarette use will have to be regulated indoors in the same manner as is done for tobacco smoking, which is prohibited indoors" [emphasis added].
“Reports of “ultra-fine particulates” found in vapor are misleading. Particulates in cigarette smoke are “solid” particulates, while particulates in vapor are water particulates (otherwise known as “droplets.”)”
The ultrafine particles created by conventional cigarettes are also droplets. 
Ultrafine particles are created by aerosolizing e-liquid to deliver doses of nicotine to the user. Aside from nicotine, the e-liquid contains propylene glycol, flavorants, heavy metals, and other chemicals formed through the chemical reactions of igniting the e-liquid. Ultrafine particles delivered by e-cigarettes are similar to conventional cigarettes (ultrafine range: modes ≈ 100-200 nm). When deeply inhaled into the lungs, ultrafine particles can contribute to cardiovascular and pulmonary diseases through several mechanisms.   
“There is no evidence youth smokers who said they use e-cigarettes were non-smokers before using e-cigarettes.”
As discussed above, more youth are initiating nicotine addiction with e-cigarettes than conventional cigarettes.  The CDC estimated that in 2013 more than a quarter-million youth who had never smoked a cigarette used e-cigarettes. 
“Non-smoking youth who try e-cigarettes may have otherwise been trying smoking if e-cigarettes had not been available.”
Youth and teen e-cigarette initiation and use rates have surpassed that of traditional smoking, with youth at low risk for initiating smoking experimenting with nicotine through new tobacco products including e-cigarettes.
In Hawaii lifetime e-cigarette use for high school students tripled, increasing from 5.1% to 17.5%, and for middle school students quadrupled, increasing from 1.8% to 7.9%, between 2011 and 2013. Of these students, approximately one-third of middle and high school e-cigarette users had never smoked a traditional cigarette.
Among Connecticut  middle school students 51% reported e-cigarettes as the first tobacco product ever used.
“The claim that adult smokers do not want ‘candy’ flavors is patently false and based on conjecture and personal bias.”
The issue is not whether adults want candy flavors; the issue is that candy flavored e-cigarettes have strong appeal for youth
This fact is not surprising, since the tobacco companies have been using flavors to recruit youth for decades (example 1, example 2, example 3, example 4).
“The CDC surveys clearly show that there has been no ‘gateway effect’ causing non-smokers to start smoking. As e-cigarettes have become more popular, all available evidence is showing that more and more smokers are quitting traditional cigarettes, including youth smokers.”
As discussed above, many youth are beginning nicotine use with e-cigarettes rather than conventional cigarettes, including many youth at low risk of ever starting to smoke conventional cigarettes.
“The only benefit of including e-cigarettes in smoking bans is protecting bystanders from infinitesimal levels of just a tiny fraction of the chemicals found in second-hand smoke.”
Yes, the benefit of including e-cigarettes in clean indoor air laws is to protect bystanders from involuntary exposure to the pollution e-cigarette users create.
As noted above, bystanders living with e-cigarette users have similar levels of cotinine – a biomarker of absorbed nicotine – as people living with cigarette smokers.  Similar results were found in a controlled experiment, together with effects on lung function of bystanders.
“Smokers move from dual use (using both the e-cigarette and conventional cigarettes) to using just the e-cigarette alone.”
As noted above, dual use is the dominant use pattern.
“Treating e-cigarettes like conventional cigarettes will just keep smokers smoking and even possibly push those dual users completely back to smoking by removing their only incentive to quit.”
One of the major reasons adult smokers use e-cigarettes is to use them where they cannot smoke conventional cigarettes.
Moreover, while there is no doubt that some people have transitioned from using cigarettes to using e-cigarettes (or even quitting both), studies of all smokers show that smokers who use e-cigarettes are about one-third less likely to stop smoking cigarettes than smokers who do not use e-cigarettes. 
You can review all Professor Stanton Glantz’ blog posts on e-cigarettes here.



BAT admits tob. smoke contains "solid non-volatile organics"
Furthermore, liquid droplets in tobacco smoke quickly coagulate in the airways
http://www.sciencedirect.com/science/article/pii/S0021850298000718" title="http://www.sciencedirect.com/science/article/pii/S0021850298000718";http...


Thank you for your critique . . .
<LI;As well as the very informative ASHRAE Review by Bud Offerman, readers could also review the AIHA White Paper on ENDS here http://tobacco.ucsf.edu/sites/g/files/tkssra4661/f/u9/AIHA-Electronc%20C... for another independent review of the literature. Needless to say, it’s conclusions are far removed from the Burnstyn/CASSA “Technical Report”, and the comments below this entry tells us much about the interests of CASSA and it’s ties to Industry, including Big Tobacco. The Burnstyn paper, which could not consider data after August 2013, is now, whatever it is or shows, way out of date. It is far from “comprehensive”, as CASSA and Clive Bates’ claim . . . .</li;
<LI;This http://www.tobaccotactics.org/index.php/Carl_V_Phillips#Funding_from_BAT... &nbsp;, on Carl V Phillips at CASSA is also enlightening . . . . &nbsp;“Phillips acted as a paid expert witness for <A title="U.S. Smokeless Tobacco Company" href="http://www.tobaccotactics.org/index.php/U.S._Smokeless_Tobacco_Company";U.S. Smokeless Tobacco Company in 2002, although his CV does not mention any papers on smokeless tobacco or oral cancer until 2006.http://www.tobaccotactics.org/index.php/Carl_V_Phillips#cite_note-CV-1";... Since Phillips received an $1.5m from USSTC for research support after his work for the company in court, it is fair to say that his expertise is build on tobacco money.” He also apparently works for BATCo, as per here: http://www.harmreductionjournal.com/content/7/1/18#sec7";http://www.harm... where it states:</li;</ol;
“Dr. Phillips has consulted for U.S. Smokeless Tobacco Company in the context of product liability litigation and is a member of British American Tobacco's External Scientific Panel.”
<LI value="3";<EM;<STRONG;“Reports of finding formaldehyde and other chemicals in e-cigarette vapor fail to disclose that the levels found (0.013 ppm), on average, are lower than can be detected in average city indoor/outdoor air (0.03 ppm).”</strong;</em;&nbsp;</li;</ol;
CASSA obviously have not read this paper http://www.mdpi.com/1660-4601/11/11/11192/htm";http://www.mdpi.com/1660-... by Bekki et al, “Externally Edited” by Dr Farsalinos, no less. He and group conclude:
“In some cases, extremely high concentrations of these carbonyl compounds are generated, and may contribute to various health effects. Suppliers, risk management organizations, and users of e-cigarettes should be aware of this phenomenon.”
David Bareham

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