Electronic Cigarette Industry Trade Association
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by Tom Pruen
Yesterday saw the publication of a report from the California Department of Public Health. Clearly, the CDPH have overcome all the health issues related to smoking, freeing up resources to address a “Community Health Threat” which has, based on all the available evidence, a negligible negative impact on health and is likely to have a significant positive one.
California has, it appears, launched a war on electronic cigarettes. It will perhaps give you some indication of how poorly-researched and dogmatically-biased the report is when Stanton Glantz, himself a world-class propagandist, described it thus:
“I have reviewed the materials that they have produced and they are world-class resources that everyone should be using”.
Prof Glantz uses an image from the report on his blog, and it is indicative of how carefully reviewed this ‘world-class resource’ is:
‘Benzenene’ is not only not an emission of ecigs, it is not a real chemical.
Sadly, the faults of this document are not just typographical, it is also one of the worst examples of cherry picking research, misleading claims, and outright lies it has been my misfortune to read. It is both too long and too filled with abuses of the evidence base to cover in detail all the issues, but here are some highlights....
It is, for example, claimed that “[t]here is no scientific evidence that e-cigarettes help smokers successfully quit traditional cigarettes”. This goes beyond the realms of cherry picking and is a deliberate and blatant lie. Even if we ignore (and there is no compelling reason why we should) the thousands of user testimonials as anecdotal, there have been a number of clinical studies. Most of these were recently summarised in a Cochrane review[i]. (Cochrane reviews are internationally acknowledged as the highest standard in evidence for healthcare decision-making). This review concluded that, although more and better-quality evidence would be helpful, “[t]here is evidence from two trials that ECs help smokers to stop smoking long-term compared with placebo ECs” and that “ECs appear to help smokers unable to stop smoking altogether to reduce their cigarette consumption when compared with placebo ECs and nicotine patches”. Since the publication of the review, more studies have been published, most recently this one[ii], which concluded “[p]articipants reduced cigarette consumption from baseline to week 4 and 8 (p's < 0.001); 23.1% reported no cigarette use in the past month at week 8” and “[i]n addition, the majority intended to use e-cigarettes as a complete replacement for regular cigarettes (69.4%)”.
There is also a big section on the calls to poison centres about electronic cigarettes, which was covered (excellently) by Clive Bates on his blog[iii] but, to put it in context, in the 2013 national report, flavoured e-cigs accounted for 1,371 mentions, while cigarettes accounted for 5,992; (neither were associated with any poisoning-related deaths in 2013). E-cigs contributed a tiny fraction of exposure reports, let alone actual poisonings, and any objective analysis would find more concerning issues to address (such as, perhaps, the 141,150 exposure reports, including 156 deaths, associated with aspirin and paracetamol).
It features (as we have unfortunately come to expect from California) a significant abuse of references, where the linked resource does not support (and, in many cases, actually contradicts) the point being made. For example, the CPHD document states: “Nicotine is a highly addictive neurotoxin, proven as addictive as heroin and cocaine.” The reference for this is “C Everett Koop, M., Health Consequences of Smoking: Nicotine Addiction a Report of the Surgeon General 1988. 1988: DIANE Publishing”. This text talks at some length about the comparative effects of nicotine and cocaine (but not heroin) in a variety of animal experiments:
In beagles: “Nicotine was an effective reinforce in all dogs: (1) peak rates of responding were about 0.3 response/sec, but higher rates of responding were maintained by cocaine”.
Beagles again: “Cocaine maintained higher fixed-ratio values than did nicotine on this progressive-ratio schedule, although maximal fixed-ratio values for nicotine were well above those for saline”.
Baboons: “rates of responding maintained by nicotine were much lower than those maintained by i.v. of cocaine”.
As well as featuring on the poorly constructed infographic , the statement is made that “e-cigarettes do not emit a harmless water vapor, but a concoction of chemicals toxic to human cells in the form of an aerosol. Vapors are purely gases, whereas aerosols also contain particulate matter.” While this is technically true, the way it is presented broadly amounts to a lie. Let’s look at the aerosol/vapour issue first.
In a technically-correct sense, a vapour is a mix of one or more chemicals in a gaseous state, and for most chemicals, this results in an invisible cloud – where the gases are indistinguishable from those already present in the atmosphere, composed as it is of oxygen and nitrogen vapours.
An aerosol is a suspension of particles in a gas, and because these particles absorb, refract or reflect light, is visible. Aerosols come in two main classifications: primary aerosols, where the particles are directly introduced to the gas (an example of which would be the solids visible in cigarette smoke), and secondary aerosols, where the particles are formed by the condensation of gaseous components. The visible emission commonly referred to as the vapour from e-cigs is, therefore, a secondary aerosol.
This also means that what we commonly refer to as ‘water vapour’, i.e. steam from a kettle, fog and clouds, are in fact aerosols; (otherwise, like the vast majority of atmospheric water vapour, they would be invisible). This can, in fact, be quite easily seen when boiling a kettle: there is often no visible steam at the mouth of the spout, as the water is actually a vapour at this point, with a long streamer of water aerosol visible above it.
Despite the implication, this clearly does not make aerosols in and of themselves dangerous; there is no particle-related risk associated with making a cup of tea or taking a shower, although both of these are significant sources of ultrafine secondary aerosols[v]. It is not surprising given the widespread misuse of the term vapour that the steam-like emissions of e-cigs are referred to as vapour, since this actually fits the common understanding of the term better than the technical one.
This brings us to the ‘concoction of chemicals’, the references for which are:
Grana, R., N. Benowitz, and S. Glantz, Background Paper on E-cigarettes. Center for Tobacco Control Research and Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control, 2013.
I won’t comment on this one here, due to both time and space constraints (and, indeed, my limited capacity for dealing with stupidity), but would suggest having a look at these sources[vi] and[vii] to gain some idea of the merit of this document.
Goniewicz, M.L., et al., Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control, 2014. 23(2): p. 133-9.
This reference, rather in contrast to the way it is presented here, reported the following:
The vapour generated from e-cigarettes contains potentially toxic compounds. However, the levels of potentially toxic compounds in e-cigarette vapour are 9–450-fold lower than those in the smoke from conventional cigarettes, and in many cases comparable with the trace amounts present in pharmaceutical preparation. Our findings support the idea that substituting tobacco cigarettes with electronic cigarettes may substantially reduce exposure to tobacco-specific toxicants. The use of e-cigarettes as a harm reduction strategy among cigarette smokers who are unable to quit, warrants further study.”
This would seem rather an odd choice to use in a publication that suggests that the use of electronic cigarettes is dangerous and should be prevented, so it would seem likely that either the author didn’t bother to read it properly (or failed to comprehend it), or that they are hoping that their target audience will blithely accept that it supports the interpretation presented, without actually reading it. Given that the general target for a public campaign is the public, who are unlikely to study the scientific literature surrounding this issue, it follows that (unless the author is actually illiterate or stupid) the intent is to deliberately misinform and deceive the public.
Interestingly, this study also measured metals in the vapour, but did not consider the levels worthy of alarmist reporting, particularly since they were also present in blank samples and the comparator pharmaceutical product:
Williams, M., et al., Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One, 2013
While the presentation of the results in this study fits quite well with the tone in which they are presented, they fail to mention an important comparator for the levels about which they express so much alarm: the levels detected per puff, adjusted to a 200 puff per day use of electronic cigarettes give a daily exposure of:
Copper: 4.06 µg
Chromium: 0.14 µg
Nickel: 0.1 µg
And the ‘important comparator’? The maximum allowable daily dose for these in inhalation medicines:
Lead 5.0 µg
Copper: 100 µg
Chromium: 25 µg
So in fact, all of these are present in harm reduction consumer products at lower daily doses than those permitted for medicinal products. This would not seem to be a great cause célèbre for raising alarm about the consumer product; if these are, indeed, such dangerous levels, perhaps the pharmaceutical guidelines would be a better target? This was covered in more depth by Prof. Siegel in his blog[viii].
Also worthy of note is that the products studied were of poor quality, and do not accurately reflect the vast majority of products on the market today. Even if they had been representative of the products on the market at the time of publication, the products have considerably evolved in the two years since the publication of the research.
The final reference is:
Schripp, T., et al., Does e-cigarette consumption cause passive vaping? Indoor Air, 2012
This study too has very limited applicability to the issue, since, although it concluded that:
“However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.”
this is not actually well-reflected in the results of the study, since the initial tests in an 8m3 chamber did not show any of the expected chemicals from vapour, suggesting that the vapour is not sustained in the air, and is dispersed and settles out quickly, limiting exposure. They also detected formaldehyde, but stated:
“This might be caused by the person in the chamber itself, because people are known to exhale formaldehyde in low amounts and the increase was already observed during the conditioning phase, furthermore the release of formaldehyde was below the limit of detection in the small scale [10 litre] experiments”.
This is also likely to apply to the detection of isoprene, since this, too, is generated by human metabolism, and is the most abundant hydrocarbon in human breath. This seems particularly likely since the levels actually dropped during the testing from 8 µg for the blank during the first two tests, before rising marginally to 10 µg for the third.
Given the low number of detections in the 8m3 test chamber, they then conducted more tests using a 10 litre vessel, however this largely invalidates the idea that passive vaping is a concern, since while people may share 8m3 rooms with others, they are significantly less likely to cohabit saucepans. A further discussion of the limits of this study can be found on the anti-THR lies blog[ix].
The risk of first- and second-hand e-cig vapour (or ‘aerosol’ for the pedantic) has been most comprehensively covered in ‘Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks.’[x]
The bizarre crusade that generated this ill-conceived and poorly executed propaganda publication – and the poorly-judged prioritisation of limited public health resources behind it – seems certain to result in net harm to the population of California. It also seems likely to be seized upon by the equally dogmatic and intellectually dishonest as an example of leading the way (bringing to mind a Star Wars quote - Who's the more foolish, the fool or the fool who follows him?) and end up having a global reach.
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