A review of E- cigaretteS

1. A review of E-cigaretteS Prepared by University of Iowa undergradutes: Maisara Abdelrazig & LauRenGaines

2. Introduction • According to the FDA, electronic cigarettes, or e-cigarettes (EC), are devices that allow users to inhale a vapor containing nicotine or other substances.1 • Unlike traditional cigarettes, e-cigarettes are generally battery-operated and use an atomizer to heat a refillable cartridge that then releases a chemical-filled vapor.1

3. Introduction cont. • E-cigarettes are often available in flavors that may appeal to children and teens, including cotton candy, bubble gum, chocolate, strawberry and mint.1 • It is estimated that there are more than 400 brands of E-cigarettes available. • Several organizations such as The World Health Organization (WHO) and The Food and Drug Administration (FDA) have expressed concerns about the health effects of using ECs.2 • The American Lung Association supports prohibiting the use of e-cigarettes under smokefree laws.

4. Examples of EC flavors

5. What Are E-cigarettes used for?: • Researchers and public health officials believe E-cigarettes can be considered a stepping stone, gateway, or bridge to start smoking • Some journals indicated that E-cigarettes are being used by cigarette companies to renormalize smoking • Many people believe they have the same “oral fixation, personal experience, and public performance of smoking” • Several surveys indicated that many E-cigarettes users used this product because they felt it: • “Helped them quit smoking, prevented exposure to smoke, allowed people to smoke in smoke free zones, and better flavor”

6. What does the EC Industry Claim?

7. Who Uses E-cigarettes? According to CDC: • During 2010 to 2011, adults reporting that they have used an e-cigarette increased among both sexes, those aged 45-54 years old, non-Hispanic Whites, those living in the South, and current and former smokers. One in five current cigarette smokers has used an e-cigarette, with their use higher than that of former or never-smokers.3 • From 2011 to 2012, the number of youth in grades 6-12 who ever used EC has doubled, and the number of those who recently used EC have almost doubled.4

8. Can E-Cigarettes Help Someone Quit Smoking? • The FDA has not approved e-cigarettes as an effective method to help smokers quit.5 • The American Lung Association does not support any direct or implied claims that e-cigarettes help smokers quit.5

9. The Vapor Content and the Health Effects of ECs ECs release numerous detectable levels of several significant carcinogens and toxins compounds into the “indoor environment”.Selected compounds that are also present in the second hand smoke of regular cigarettes includethe following6 :

10. The Vapor Content and the Health Effects of ECs cont. • 1,2-Propanediol • 1-Hydroxy-2-propanone • 2,3-Butanedione • 2,5-Dimethylfuran • 2-Butanone (MEK) • 2-Furaldehyde • 2-Methylfurane • 3-Ethenyl-pyridine • Toluene • Acetaldehyde • Acetic acid • Acetone • Benzene • Isoprene • Limonene • m, p-Xylene • Phenol • Pyrrole • Formaldehyde • Propanal.6

11. The Vapor Content and the Health Effects of ECs cont. • No brand of e-cigarettes has been submitted to the FDA for evaluation of their safety.5 • Threatens ban on public smoking • In initial lab tests conducted in 2009, FDA found detectable levels of toxic cancer-causing chemicals, including an ingredient used in anti-freeze, in two leading brands of e-cigarettes and 18 various cartridges.5 • The lab tests also found that cartridges labeled as nicotine-free had traceable levels of nicotine.5 • A study has found out that the nicotine content of the studied ECs’ liquids varied and was 1.2-fold higher than what the manufacturer claimed.7 • There is no evidence that shows the vapors emitted by e-cigarettes are safe for non-users to inhale.5

12. The Vapor Content and the Health Effects of ECs cont. • A research on the “Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function” concluded that, for the e-cigarettes tested, the effect of active and passive e-cigarette smoking on serum cotinine levels is similar to that generated by tobacco cigarette smoking.8

13. The Vapor Content and the Health Effects of ECs cont. • Regarding short-term usage, the studied e-cigarettes generate smaller changes in lung function but similar nicotinergic impact to tobacco cigarettes.8

14. The Vapor Content and the Health Effects of ECs cont. • Another study indicated that some EC samples have cytotoxic properties on cultured myocardial cells, associated with the production process and materials used in flavorings.9 • However, all EC vapor extracts were significantly less cytotoxic compared to regular cigarette smoke extract.9

15. The Vapor Content and the Health Effects of ECs cont. • A review of chemical analyses of EC liquid found that nitrosamines were present at levels 500–1,400 times lower compared to smoking10. • Goniewiczet al. observed that the amount of carbonyls produced by EC use in laboratory conditions was 9–450 times lower compared to tobacco cigarettes.10 • Another study concluded that: “Our data confirm that e-cigarettes are not emission-free and their pollutants could be of health concern for users and secondhand smokers. In particular, ultrafine particles formed from supersaturated 1,2-propanediol vapor can be deposited in the lung, and aerosolized nicotine seems capable of increasing the release of the inflammatory signaling molecule NO upon inhalation. In view of consumer safety, e-cigarettes and nicotine liquids should be officially regulated and labeled with appropriate warnings of potential health effects, particularly of toxicity risk in children.”7

16. The Vapor Content and the Health Effects of ECs cont. • However, it is not known, and is still too early to evaluate, whether reduction or complete substitution of smoking by EC use has any long-term health benefits.10

17. Can EC Cause Passive Vaping? • The consumption of e-cigarettes (vaping) causes emissions of aerosols and volatile organic compounds (VOCs), such as 1,2-propanediol, flavoring substances, and nicotine, into indoor air.11 • During inhalation of e-cigarette vapor, the aerosol size distribution alters in the human lung and leads to an exhalation of smaller particles.11

18. Can EC Cause Passive Vaping? Cont. • The quantity of the inhaled vapor could be observed to depend on the liquiddelivery system of the e-cigarette in use.11 • As a consequence, passive vapingmust be expected from the consumption of e-cigarettes.11 • The e-cigarette is a new source of VOCs and ultrafine/fine particles (FP/UFP)in the indoor environment.11

19. The Health Hazards of ECs Generally, the overall picture of the health hazards of ECs is still unclear, especially for long term use, and further research needs to be done.

20. Legislation of EC • E-cigarettes have been banned in Australia, Canada, Singapore, and Brazil because of the lack of data about their safety or efficacy • On April 25, 2011, the U.S. Food and Drug Administration (FDA) announced that e-cigarettes will be regulated as tobacco products unless the products are marketed as therapeutic, making a claim that e-cigarettes can help someone quit smoking for example.5 • Over 14 Agencies including American Heart and Lung Association, American Public Health Association, The American Academy of Pediatricians, The American College of Preventative Medicine, and the American Cancer Society (to name a few) have sent a letter to the FDA Urging Regulation.5

21. Legislation of EC cont. • In September 2013, Iowa Attorney General (AG) Tom Miler said he and 36 state attorneys general and attorneys general in three U.S. territories, signed a bipartisan letter asking the US Food and Drug Administration (FDA) to prohibit the sale of ECs to minors, and restrict their ingredients and advertising.12 • The attorneys general asked the FDA to immediately take all available measures to regulate ECs as tobacco products under the Tobacco Control Act.12

22. Legislation of EC cont. Currently many US states and counties have passed laws to regulate the use of EC. • 3 states that passed laws restricting EC use in 100% smokefree venues: North Dakota, New Jersey, and Utah. • 9 states that passed laws restricting EC use in other venues: AR, CO, DE, KS, MD, NH, OK, OR, and SD. • 108 local laws restricting EC use in 100% smokefree venues.

23. Legislation of EC cont. • New York City is the last city that passed a bill to regulate the use of EC. • Michael Bloomberg, the mayor of New York City, signed the legislation on 12/30/13 to amend the Smoke-Free Air Act, which bans smoking in public places and places of employment. The act now additionally prohibits the use of electronic cigarettes in all areas where smoking is prohibited.

24. Policy Options: • Regulating Sale • Regulate Marketing • Regulate Price • Regulate Use • Clearly define E-cigarettes Laws

25. References 1. U.S. Food and Drug Administration. “FDA Warns of Health Risks Posed by E-Cigarettes.” July 23, 2009. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm173401.htm.   2. Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Bocchietto E, Todeschi S, Tsiapras D, Kyrzopoulos S, Voudris V. Comparison of the Cytotoxic Potential of Cigarette Smoke and Electronic Cigarette Vapour Extract on Cultured Myocardial Cells. International Journal of Environmental Research and Public Health. 2013; 10(10):5146-5162. 3. King BA, Alam S, Promoff G, Arrazola R, Dube SR. “Awareness and Ever Use of Electronic Cigarettes Among U.S. Adults, 2010–2011.” Nicotine & Tobacco Research. February 2013; 15:1623-7.

26. References cont. 4. Centers for Disease Control and Prevention. “Electronic Cigarette Use Among Middle and High School Students — United States, 2011–2012.” Morbidity and Mortality Weekly Report. September 6, 2013; 62(35):729-30.   5. E-cigarettes. American Lung Association Web site. http://www.lung.org/associations/states/oregon/assets/docs/e-cigarette-fact-sheet.pdf. Updated 2013. Accessed 12/25, 2013. 6. Schripp T, Markewitz D, Uhde E, Salthammer T. Does e- cigarette consumption cause passive vaping? Indoor Air. 2013;23(1):25. 7. Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. (0). 

27. References cont. 8. Flouris, Andreas Chorti, Maria Poulianiti, KonstantinaJamurtas, AthanasiosKostikas, KonstantinosTzatzarakis, Manolis Wallace Hayes, A Tsatsakis,AristidisKoutedakis, Yiannis. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. InhalToxicol. 2013;25(2):91-101. 9. Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Bocchietto E, Todeschi S, Tsiapras D, Kyrzopoulos S, Voudris V. Comparison of the Cytotoxic Potential of Cigarette Smoke and Electronic Cigarette Vapour Extract on Cultured Myocardial Cells. International Journal of Environmental Research and Public Health. 2013; 10(10):5146-5162.

28. References cont. 10. Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Bocchietto E, Todeschi S, Tsiapras D, Kyrzopoulos S, Voudris V. Comparison of the Cytotoxic Potential of Cigarette Smoke and Electronic Cigarette Vapour Extract on Cultured Myocardial Cells. International Journal of Environmental Research and Public Health. 2013; 10(10):5146-5162. 11. Schripp T, Markewitz D, Uhde E, Salthammer T. Does e- cigarette consumption cause passive vaping? Indoor Air. 2013;23(1):25. 12. Local news | iowa city press citizen | press-citizen.comhttp://www.press-citizen.com/article/20130924/NEWS01/130924010/Iowa-AG-Tom-Miller-wants-FDA-ban-e-cigarette-sales-minors?nclick_check=1. Accessed 12/20/2013, 2013.