The truth about e-cigs: it gets clingy: testimony from a cancer researcher

Electronic cigarettes are a rapidly growing public health problem nationwide, with huge increases in use among children. For many years, selling cigarettes to minors has been illegal, but no such law exists for e-cigs. Last year, the FDA proposed to ban sales of electronic cigarettes to minors, but it may take years to go into effect. Many kids know the dangers of smoking, but mistakenly believe these new products don’t contain tobacco or nicotine.

EnviroMedia recently developed one of the country’s first behavior change campaigns about e-cigs, vaping and hookahs for a coalition of Texas colleges. Peers Against Tobacco is distributing the “It gets clingy” print and social media campaign materials, which highlight the addictive nature of nicotine in these products.

I’ve known Dr. Joel Dunnington since my days working with the American Lung Association in the early 1990s. For decades, he’s been fighting to save lives from the harmful effects of tobacco use. He’s a bold physician and cancer researcher, fighting against the tobacco industry for stronger public health policy in the state of Texas. Although he recently retired as a faculty member from M.D. Anderson Cancer Center, he’s still fighting for the cause at the state capitol. Below is his recent testimony he presented March 11, 2015 to the Texas House Public Education Committee, concerning HB 456, which would prohibit vapor products from school property.

E-Cigarette Primer v.3, by Joel Dunnington MD, FACR

First of all, let’s understand the industry we are talking about. The tobacco industry has been sued by the Department of Justice in the largest Civil Racketeer Influenced and Corrupt Organization (RICO) lawsuit in US history. They were found guilty in 2006. We are still waiting for them to publish the Corrective Statements. The Tobacco Industry has been fighting against the Corrective Statements for the last eight years. Most of you have never heard of this landmark case. Unfortunately for the tobacco victims, it should have been a Criminal Racketeering conviction and they should be in prison today.

Cigarettes have been around in some form since the 1800s. But cigarettes smoking really started growing in the early 1900s with the advent of modern advertising. The first articles on tobacco caused diseases appeared in the late twenties and thirties, mostly from Germany. There were a few American scientific articles during that time and a few more in the forties. The first large scale epidemiology studies appeared in the early fifties. There are now over 80,000 articles published on the health effects of tobacco. So, the major articles demonstrating that smoking caused disease appeared 50 years after the introduction of the modern cigarette. We are still adding to the list of tobacco caused diseases today. Do we really want to have another fifty year experiment with human guinea pigs to see if E-cigarette usage also causes many different health problems?

According to its own documents, the tobacco industry has known that its products kill its best customers for at least the last sixty years. They did nothing about changing the product or removing it from the market. They have known for at least fifty years that their products contain nicotine and are very addicting. They have done nothing about that fact, other than adding and manipulating chemicals to make them more addicting. No other industry or manufacturer in America has been allowed to get away with anything like this. They are protected by many state and federal laws. The tobacco industry does not have to put an ingredient label on cigarettes, but the candy cigarette manufacturers have to label their product. They are protected from lawsuits in most states, including Texas.

With all of this background, why would anyone start a new industry in 2007 selling the same nicotine? Why would there be 466 new E-cigarette companies formed around the world in the last eight years? Why would vaping shops spring up all across our towns? Why would there be thousands of E-cigarette websites? I believe the answer is money. As Warren Buffett put it many years ago, "I'll tell you why I like the cigarette business. It cost a penny to make. Sell it for a dollar. It's addictive. And there's a fantastic brand loyalty”. That probably also holds true for E-cigarettes. The E-cigarette industry likes to paint themselves as mom and pop stores and small business manufacturers that are not aligned with “Big Tobacco”. They claim they are just trying to help smokers quit using cigarettes (see below). However, I believe this should be viewed as one big industry. The major tobacco companies have all bought or produced E-cigarette products. The major tobacco companies now have almost 50% of the E-cigarette market at convenience stores. The advertising to adults and children are the same for E-cigarettes and cigarettes.

Electronic cigarettes are battery powered devices designed to aerosolize nicotine and various flavoring agents so they can be inhaled by the user. These are suspended in propylene glycol and/or glycerol. There is no water, none, in e-cigarette vapor!

E-cigarettes were invented by a Chinese pharmacist named Hon Lik in 2003. The patent application states “An electronic atomization cigarette that functions as substitutes for quitting smoking and cigarette substitutes “. E-cigarettes were brought on the market in 2007.

There are multiple names that are used for “Electronic cigarettes”.

ENDS-Electronic Nicotine Delivery Systems, Electronic Cigarettes, e-cigarettes, e-cigs, e-cigars, e-hookah, hookah pens, E-hookah, vape pipes, vape pens, e-Vapor Device, personal vaporizer, vapor cigarette.

Construction

E-cigarettes are constructed with a battery, a cartridge to hold the nicotine and flavors, an atomizer with a heating element to aerosolize the nicotine, and some have an LED on the tip. Newer models have the same basic components, but they often do not look like a cigarette.

Disassembled cigarette-styled electronic cigarette. A. LED light cover B. battery (also houses circuitry) C. atomizer (heating element) D. cartridge (mouthpiece)

Wikipedia http://en.m.wikipedia.org/wiki/Electronic_cigarette

An atomizer is a component of the e-cigarette that heats up the nicotine. It has a small heating element to vaporize the nicotine and wicking material to bring the nicotine to the heating element. Many different types of material are used as wicking material. A cartomizer (cartotank) is an atomizer surrounded with liquid soaked foam that holds the e-liquid. A clearomizer (clearo) is a clear tank in which an atomizer is inserted. A rebuildable atomizer (RBA) can be modified so the user can customize the construction with different wicks and coils.

There are three generations of e-cigarettes.

The first generation are called “cigalikes” and have a low voltage battery. The lower voltage battery does not vaporize the nicotine as effectively and produces a lower dose of nicotine. Some of these are for one time use and some are rechargeable. Some have a reusable cartridge and battery together that is called a cartomizer. Since some of these have enough nicotine to last for a week, some people have overdosed and become sick by using it all in one day.

The second generation e-cigs are larger than the first generation and do not look like cigarettes. They often resemble large colored pens. They have larger batteries and tanks. The tanks are refillable with e-juice. The batteries are usually rechargeable by USB ports. They produce higher temperatures and thus higher levels of nicotine.

The third generation of e-cigs use even larger batteries and tanks. These usually look nothing like cigarettes. Some are called “mechanical mods” and some are variable voltage devices. Some of these can be modified with different batteries, different wicks and different atomizers. The mods do not have circuitry. These are usually used by more experienced vapers. However modifying e-cigs can be dangerous. Several have exploded.

E-liquid or E-juice is a solution of propylene glycol and/or glycerol that contains nicotine with flavors. There may also be a small amount of alcohol. There is no water. The nicotine is derived from tobacco plants, it is not synthesized. The nicotine can be in different strengths. Researchers found that there were 7,700 E-cig flavors in January 2014. They estimated another 240 new flavors are introduced each month. Some E-juice contains no nicotine, but these are not big sellers. There are several different nicotine concentrations available. The most popular nicotine concentration reportedly is 18mg/ml.

Nicotine is a very toxic substance. From the MSDS Toxicology Data Sheet for nicotine, “Acute Potential Health Effects: Skin: It can cause skin irritation and rash. It may cause dermatitis. It is well absorbed by dermal exposure route. May be fatal if absorbed through skin. Systemic effects similar to that of ingestion can occur from nicotine poisoning. Eyes: It can cause eye irritation. Severe pain, lacrimation, conjunctival reaction, corneal infiltration, partial opacification of cornea. Inhalation: It is well absorbed by inhalation exposure route. Inhalation can produce systemic effects similar to that of ingestion. Ingestion: May be fatal if swallowed. It can cause gastrointestinal tract irritation/disturbances with nausea, vomiting, diarrhea, stomach pain, burning sensation of the mouth, throat, esophagus, and stomach, loss of appetite. Metabolic acidosis and hypokalemia can develop if there is severe diarrhea. It acts on the central nervous system and other parts of the nervous system such as the adrenal medulla, autonomic ganglia, and neuromuscular junctions with initial stimulation followed by depression. Early signs of toxicity from small doses include nausea, vomiting, headache, dizziness, tachycardia, hypertension, tachypnea, hyperpnoea, sweating, and salivation. High exposure can cause dizziness, headache, tremors, anxiety, restlessness, seizures, hypotonia, decreased deep tendon reflexes progressing to paralysis, fasciculation, convulsions, weakness, incoordination, hallucinations, confusion, and coma. Hypertension, tachycardia, and tachypnea followed by hypotension, bradycardia, and dyspnea, bradypnea can occur. Tachypnea is one of the principle signs nicotine poisoning. Respiratory failure may also occur. Other symptoms can include weak, rapid, and irregular pulse. Vasoconstriction, atrial fibrillation, and sinoatrial block, and ventricular fibrillation have also all been reported. Death is usually from respiratory depression secondary to CNS depression and peripheral blockade of respiratory muscles.”

Nicotine in small doses is extremely addicting. Nicotine in slightly larger doses can be deadly. With the advent of e-cigarettes, quantities of liquid nicotine are now readily available from stores and the internet. These are usually sold in containers that are not child-proof. The nicotine level in E-liquid bottles come in a variety of strengths. However, pure nicotine is readily available for people who like to mix their own E-liquid. Some of these containers are 32 ounces in size of pure nicotine. This amount of pure nicotine is enough to kill thousands of adults.

Vaping proponents have made statement in many venues that nicotine is no worse than caffeine. This is not true. It is far more addicting and more dangerous. And pure nicotine is very dangerous to handle. The vaping proponents often compare the E-liquid juice to other household products that are dangerous. But all of these dangerous household products are sold in child-proof containers and the majority are not nearly as dangerous as nicotine. The number of calls to Poison Control Centers for nicotine poisoning have steadily increased.

Nicotine has been shown to be a tumor promoter and to increase metastatic disease. Nicotine when burned changes into NNK, which is a carcinogen. Nicotine when vaporized at high temperatures can produce a number of different toxic chemicals that are not seen in the lower voltage E-cigarettes. As the voltage on E-cigarettes increases with larger devices, more toxins are produced by the increased temperature on the coils.

Use by Children

The 2011 and 2012 National Youth Tobacco Survey (NYTS) revealed that e-cigarette use among youths in grades 6 through 12 doubled between 2011 and 2012, from 3.3% to 6.8%. As with adults, concurrent dual use of e-cigarettes and conventional cigarettes was also high, with 76.3% of current e-cigarette users reporting concurrent use of conventional cigarettes in 2012. United States, 2011-2012.MMWR Morbidity Mortality Wkly Rep. 2013;62(35):729-730.

Adolescents who had ever experimented with cigarettes (smoked at least a puff) and used e-cigarettes were more likely to report having smoked at least 100 cigarettes and to be current smokers than adolescents who never used e-cigarettes. Thus, in combination with the observations that e-cigarette users are heavier smokers and less likely to have stopped smoking cigarettes, these results suggest that e-cigarette use is aggravating rather than ameliorating the tobacco epidemic among youths. These results call into question claims that e-cigarettes are effective as smoking cessation aids. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488 Published online March 6, 2014.

On December 18, 2014, the California Department of Education reported that e-cigarettes were being adopted much faster than conventional cigarettes among California youth. These data, collected from over 450,000 youth during the 2013-4 school year showed that 3.9 times as many 7th graders were using e-cigarettes than conventional cigarettes, 2.3 times as many 9th graders, 1.7 times as many 12th graders, and about the same rate (1.1 times) for nontraditional (continuation, community day, and other alternative school types) students. http://tobacco.ucsf.edu/more-evidence-california-kids-are-rapidly-taking-ecigs-faster-market-penetration-among-younger-kids

If large numbers of adult smokers become users of both traditional cigarettes and e-cigarettes — rather than using e-cigarettes to quit cigarettes completely — the net public health effect could be quite negative,” Tim McAfee, MD MPH, director of the Office on Smoking and Health at CDC

Use by Adults

From an article in Nicotine and Tobacco Research in 2014 in an article titled: Trends in Electronic Cigarette Use Among U.S. Adults: Use is Increasing in Both Smokers and Nonsmokers

Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18–24 (14.2%) was higher than adults 25–44 (8.6%), 45–64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers. http://ntr.oxfordjournals.org/content/early/2014/11/06/ntr.ntu213.abstract

E-cigarette companies

Seven of the Major Tobacco Companies now own E-cigarette Companies

Altria- NuMark subsidiary with MarkTen 2012 and Green Smoke 2013

Reynolds American (R.J. Reynolds Vapor Co.) - Vuse

Lorillard (LOEC) - Blu e-cigs 2012, SkyCigs 2013

BAT- Vype and CN Creative

Imperial TobaccoPuritane

Swisher International - e-cigars

Japan Tobacco Company - Ploom

(Please note this may change in the near future if RAI and Lorillard merge.)

Market Share:

While Blu (owned by Lorillard) and NJOY dominate the e-cigarette market today, with the marketing prowess of the major tobacco companies, this may change in the near future with Vuse and MarkTen, which were released nationally in 2014. As of January 2014 there were 466 smaller E-cigarette companies and another 10 companies are started each month.

Regulations

The FDA ban on flavored cigarettes (menthol not banned) does not apply to E-cigarettes. E-cigarettes are not taxed by the Federal Government. They are taxed by only a few states. The FDA has proposed regulations on E-cigarettes, but they may not be in force for years. The FDA did not even propose regulating the thousands of flavors in e-cigarettes. There is no analysis or regulation of the flavors that e-cigarette companies place in their product. There is no national regulation on sampling of E-cigarettes to youth.

Size of the Problem

There are an estimated 2.5 million “vapers” in the world and the E-cigarette revenue is estimated to be $3.5 billion in 2012. Financial industry pundits suggest that worldwide sales may each $10 billion in 2017. Apparently the personal vaporizer type devices have surpassed the sale of the cigalikes type devices in the US.

Definition of E-cigarettes

From the ANR Model Smokefree Ordinance- “Electronic Smoking Device” means any product containing or delivering nicotine or any other substance intended for human consumption that can be used by a person to simulate smoking through inhalation of vapor or aerosol from the product. The term includes any such device, whether manufactured, distributed, marketed, or sold as an e-cigarette, e-cigar, e-pipe, e-hookah, or vape pen, or under any other product name or descriptor. http://www.no-smoke.org/pdf/modelordinance.pdf

It is important that this definition be placed in the section of the law under tobacco policy, and not in a separate place.

It is important that there not be any specific or implied preemption of local ordinances by a state law. This has been passed in many states. This precludes local governments from passing more comprehensive E-cigarette ordinances. It is better to explicitly state that this law does not pre-empt local ordinances.

The definition should not exclude products that do not contain nicotine, because his may allow a loophole where people may purchase E-cigs and the nicotine cartridges separately.

The definition should not use “tobacco derived nicotine”. Although almost all nicotine is derived from tobacco and it is very expensive to chemically manufacture nicotine at this time, in the future with genetic engineering, a method may be found to produce large quantities of nicotine economically.

Be very careful of industry sponsored separate definitions for “alternative nicotine products” and “vapor products.”

Dangers of E-cigarettes

Cigarettes kill 480,000 Americans and 28,000 Texans a year. This is the largest preventable public health problem in the US and Texas. First and foremost, E-cigarettes are not nearly as dangerous as regular cigarettes. That said, is that the goal we should be aiming at? Or should we be comparing it with clean air or nicotine replacement therapy that is FDA approved. E-cigarettes are not FDA approved.

They are essentially unregulated. Many are built in China and the quality control, when measured different ways and by different groups, is poor. The labeled levels of nicotine often have a large margin of error. From poor soldering and construction, some e-cigarettes that have been analyzed have produced high levels of toxic heavy metals.

The human body is very efficient at detoxifying chemicals ingested orally. These pass into the digestive system and the chemicals are picked up from the intestines and flow into the liver. The liver has many biochemical pathways to break down toxins and chemicals. The lungs do not possess these biochemical pathways to detoxify chemicals.

E-cig emissions

· E-cigarette aerosol is made up of a high concentration of ultrafine particles, and the particle concentration is higher than in conventional tobacco cigarette smoke.

· Exposure to fine and ultrafine particles may exacerbate respiratory ailments like asthma, and constrict arteries which could trigger a heart attack.

· At least 10 chemicals identified in e-cigarette aerosol are on California’s Proposition 65 list of carcinogens and reproductive toxins, also known as the Safe Drinking Water and Toxic Enforcement Act of 1986. The compounds that have already been identified in mainstream (MS) or secondhand (SS) e-cigarette aerosol include: Acetaldehyde (MS), Benzene (SS), Cadmium (MS), Formaldehyde (MS,SS), Isoprene (SS), Lead (MS), Nickel (MS), Nicotine (MS, SS), N-Nitrosonornicotine (MS, SS), Toluene (MS, SS).

· E-cigarettes contain and emit propylene glycol, a chemical that is used as a base in e-cigarette solution and is one of the primary components in the aerosol emitted by e-cigarettes.

· Short term exposure causes eye, throat, and airway irritation.5

· Long term inhalation exposure can result in children developing asthma.

· Even though propylene glycol is FDA approved for use in some products, the inhalation of vaporized nicotine in propylene glycol is not. Some studies show that heating propylene glycol changes its chemical composition, producing small amounts of propylene oxide, a known carcinogen.

· There are metals in e-cigarette aerosol, including chromium, nickel, and tin nanoparticles.

· FDA scientists found detectable levels of carcinogenic tobacco-specific nitrosamines in e-cigarette aerosol.

· Many of the elements identified in the aerosol are known to cause respiratory distress and disease. The aerosol contained particles >1 μm comprised of tin, silver, iron, nickel, aluminum, and silicate and nanoparticles (<100 nm) of tin, chromium and nickel. The concentrations of nine of eleven elements in e-cigarette aerosol were higher than or equal to the corresponding concentrations in conventional cigarette smoke.

· Short term use of e-cigarettes has been shown to increase respiratory resistance and impair lung function, which may result in difficulty breathing.

· Overall, e-cigarettes are a new source of Volatile Organic Compounds (VOCs) and ultrafine/fine particles in the indoor environment, thus resulting in “passive vaping.”Americans for Nonsmokers’ Rights, © 2014

In addition to the above hazards, multiple E-cigarette with their lithium batteries have exploded, especially while charging. These have caused fires and injuries. Some of these were from E-cigs that had been modified, but a number were not modified.

Flavors

While the flavors used in E-cigarettes are usually Generally Recognized as Safe (GRAS) and approved for human use when ingested orally, very few of these have ever been analyzed for their adverse effects when inhaled. There are a number that have shown adverse effects when inhaled and there are inhalation precautions advised for workers using these flavors in the workplace.

From the Flavor and Extract Manufacturers Association: The Safety Assessment and Regulatory Authority to Use Flavors — Focus on E-Cigarettes

2. None of the primary safety assessment programs for flavors, including the GRAS program sponsored by the Flavor and Extract Manufacturers Association of the United States (FEMA), evaluate flavor ingredients for use in products other than human food. FEMA GRAS™ status for the use of a flavor ingredient in food does not provide regulatory authority to use the flavor ingredient in e-cigarettes in the U.S.

· E-cigarette and flavor manufacturers and marketers should not represent or suggest that the flavor ingredients used in e-cigarettes are safe because they have FEMA GRAS™ status for use in food because such statements are false and misleading.

· E-cigarette manufacturers and marketers should take appropriate action to assure the safety of flavor ingredients used in e-cigarettes. FEMA GRAS™ status for the use of flavor ingredients in food does not mean that FEMA GRAS™ flavor ingredients are safe for use in e-cigarettes.

Cessation

E-cigarettes are not FDA approved for smoking cessation. The company’s manufacturing and distributing them cannot claim that these are good for smoking cessation. The companies have not made application to the FDA to get approval for use in smoking cessation. They have not sponsored the Clinical Research Trials necessary to prove that E-cigarettes are smoking cessation devices.

However that has not stopped the Vape shops from telling customers they can quit cigarettes with E-cigarettes. It has not stopped the E-cigarette front groups from promoting E-cigs as cessation devices. It has not stopped a plethora of scientific “advocates” that produce volumes of press promoting the cessation properties of E-cigarettes. Most of the research on cessation shows modest, if any evidence that it is useful for cessation. A number of these studies were paid for by the E-cigarette industry. There is considerable evidence that many E-cigarette users are dual users, meaning they also continue to smoke cigarettes. So there is no health benefit to their E-cigarette usage.

Other Constituents

E-cigarettes can be used with over 8,000 different flavors, along with nicotine. However, there is now E-cigarette liquid that contains Tetrahydrocannabinol (THC), the primary ingredient in marijuana. This can be smoked in school bathrooms, or anywhere else, and unlike marijuana it will be very difficult to detect.

Marketing

The E-cigarette companies are using the same advertising and marketing tactics long used by the tobacco companies to attract adults and children. A report by the Center for Tobacco Free Kids illustrates how many of today’s E-cigarette ads closely resemble the cigarette ads of old. And since there is no advertising restrictions for E-cigarettes on TV, these are being show on prime time TV. They are in magazines read by youth and there are many celebrity endorsements. E-cigarettes have a very large internet presence, both with their company websites and thousands of YouTube testimonials on how great they are. They have appeared in TV shows and movies, probably as product placements.

A Vuse E-cigarette ad on a convenience store door. Is this at an adult’s belt buckle height, or a kid’s eye level?

A Blu E-cigarette ad from the Sports Illustrated Swimsuit Issue, 2014. They claim they do not advertise to children and teens, but to me this ad is aimed at teens and young males. 70 million viewers according to SI.

E-cigarette displays are often immediately adjacent to the candy on the counter, just like the cigarette companies used to do.

Front Groups and E-cigarette (Tobacco) Industry Tactics

The E-cigarette industry has developed many lobbying groups set up very much like the tobacco industry. Or they have utilized existing think tanks that have a long histories of funding from and collaboration with the tobacco companies. These include the American E-liquid Manufacturing Association, The National Vapers Club, Consumer Advocates for Smoke-free Alternatives Association, Smoke-Free Alternative Trade Association, Citizens Lobbying against Smoker Harassment, The Electronic Cigarette Industry Group, Inc., Council of Independent Tobacco Manufactures of America, Smoke-Free Alternative Trade Association, Electronic Cigarette Trade Association, Tobacco Harm Reduction, Electronic Cigarette Industry Group, Tobacco Vapor Electronic Cigarette Association, National Centre for Public Policy Research, Oklahoma Vapors Advocacy League and the American Council on Science and Health. The list is longer.

Any time a reporter writes a bad article about E-cigarettes, the reporter and the comments section are inundated with comments by many “Vapers” and members of these groups. These comments frequently come from all across the US and the globe. They also fly consultants to talk to city councils, state legislatures, and to Congress. Another tobacco industry tactic the E-cigarette industry uses is paying for research and researchers. So be very careful when you see E-cigarette scientific journal articles. Look who funded the research. This is one of the tobacco industry tactics that got them convicted of Racketeering.

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