N O V E M B E R

2 0 1 3

PUBLIC HEALTH ADVISORY

ALERT TO CONSUMERS OF ELECTRONIC CIGARETTES, ELECTRONIC NICOTINE DELIVERY SYSTEMS (ENDS) AND OTHER VAPOR PRODUCTS:
This Oklahoma State Department of Health E-Public Health Advisory dated Nov. 2013 makes some very questionable claims about e-cigarettes and takes leaps of logic that must be addressed. The following document contains OSDH statements from their Advisory, each followed by a response from those whose life and health has been improved by the use of these personal vapor devices or e-cigarettes. We are disturbed to find that our public health officials are circulating misleading, unscientific or unsubstantiated information on matters that affect public health and policy making.

OSDH: All consumers are advised to use caution when using or considering the use of electronic cigarettes, electronic nicotine delivery systems (ENDS) and other vapor products.
Response: How much caution is actually warranted given what we know about the dangers of smoking? We have every reason to believe the hazard posed by electronic cigarettes would be much lower than 1% of that posed by (tobacco) cigarettes . . .if we get all tobacco smokers to switch from regular cigarettes (to electronic cigarettes), we would eventually reduce the US death toll from more than 400,000 a year to less than 4,000, maybe as low as 400. --Joel Niztkin, MD, MPH, DPA, FACPM, Chair, Tobacco Control Task Force, American Association of Public Health Physicians Scientific integrity does not permit the asse rtion that anything is safe. What is known, however, is that this product, per numerous scientific studies, is much safer, by orders of magnitude, than, tobacco cigarettes.

OSDH: E-cigarettes/vapor products contain chemicals, including nicotine, which is toxic and highly addictive. Nicotine affects the nervous system and heart and can be absorbed into the body through inhalation, ingestion and skin contact. Excessive exposure to nicotine can result in poisoning particularly in young children and pets. Liquid contained or used in e-cigarette or vapor devices should not be accessible to children. Response: The dose makes the poison (principle of toxicology) All chemicalseven water and oxygen
can be toxic if too much is consumed. Nicotine containing products such as tobacco, FDA approved nicotine replacement patches, nicotine gum and mint flavored lozenges have a history of sickening children. Nicotine containing vapor liquid should, of course, be kept out of reach of children.

OSDH: Because all nicotine is derived from tobacco, it contains tobacco-related contaminants that can be harmful.
Response: Nicotine is a naturally occurring chemical found in at least 66 other species of plants. Nicotine is extracted from tobacco plants simply because it is the most cost effective. As our friends at NYSmokefree.com point out, It is NOT the nicotine in cigarette smoke that causes cancer. Nicotine may keep you smoking, but it is the other bad chemicals in cigarettes that make smoking so dangerous.

OSDH: E-cigarettes/vapor products emit vapor that contains propylene glycol and tobacco- related 1 contaminants such as formaldehyde and tobacco-specific nitrosamines. The vapor produced by these products

is NOT water vapor.

Response: The lifetime of e-cigarette vapor is roughly 11 seconds. Cigarette smoke, on the other hand, takes about 19-20 minutes to dissipate. That is because smoke and vapor are different. Vapor contains no toxic tar or carbon monoxide or many of the roughly 4,000 toxic compounds identified in cigarette smoke. Propylene glycol (PG) is listed by the Food and Drug Administration as GRAS (Generally Recognized as Safe) It is PG present is thousands of foods, cosmetics and pharmaceutical products including FDA approved smoking cessation inhalers and asthma breathing treatments. If propylene glycol is harmful when inhaled, the government and many pharmaceutical companies have some explaining to do. Alternately, vegetable glycerin, also GRAS, is used to produce the vapor in personal vapor devices. As for the Nitrosamines; Nitrosamine levels in e-cigarettes have been found to be similar to the levels in Nicorette gum and NicoDerm patches, but less than one-hundredth to one-thousandth the level in a wide range of smokeless tobacco and cigarette products . Dr. Joel L. Nitzkin (Formaldehyde see below)

OSDH: E-cigarettes/vapor products should not be used indoors or in cars.

Response: Smoking bans are justified because of risk posed to others by environmental tobacco smoke. Most of the air pollution due to cigarettes comes from the sidestream smoke. That is the smoke that is produced by the burning tip of a lit cigarette. E-cigarettes contain no tobacco and are not burning so there is no sidestream smoke or other toxic products of combustion.

OSDH: Secondhand vapor carries toxins that impact non-users. Bystanders can inhale nicotine, propylene glycol and tobacco-related contaminants, such as formaldehyde, acetaldehyde, and acrolein.
Response: The OSDH cites utterly misrepresented German research for these claims. Formaldehyde sounds really scary but did you know it is present in our breath? The actual research that OSDH is basing this claim on did show a minute increase in formaldehyde that began when the subjects entered the test room and BEFORE they even began using the e-cigarette. In the study cited by OSDH the researchers themselves note that the increase in formaldehyde might be caused by the person in the chamber itself, because people are known to exhale formaldehyde in low amounts If OSDH expects Oklahomans to trust their word on critical matters regarding health, they should be more careful. The truth is that there is no evidence to conclude that E-cigarette vapor poses any danger to bystanders. PubMed: Consulting for Health, Air, Nature, & A Greener Environment, LLC: "Non-cancer risk analysis revealed. No Significant Risk" of harm to human health for vapor samples from e-liquids (A-D) . . .With regard to cancer risk analysis, no vapor sample from eliquids A-D exceeded the risk limit for either children or adults. . . . The study indicates no apparent risk to human health from e-cigarette emissions based on the compounds analyzed." According to researchers, the lifetime of electronic cigarette vapor is roughly 11 seconds (compared to 19-20 minutes that cigarette smoke lingers) and electronic cigarettes represent no real risk of passive 2 or secondhand vaping.

Drexel University's School of Public Health finds similar: By reviewing over 9,000 observations about the chemistry of the vapor and the liquid in e-cigarettes, Dr. Burstyn was able to determine that the levels of contaminants e-cigarette users are exposed to are insignificant, far below levels that would pose any health risk. Additionally, there is no health risk to bystanders. Proposals to ban e-cigarettes in places where smoking is banned have been based on concern there is a potential risk to bystanders, but the study shows there is no concern. Banning e-cigarettes as if they were no different from toxic cigarette smoke is unjustified and actually works against the interests of public health by making safer alternatives to tobacco difficult to access and use.

OSDH: E-cigarettes should not be used by or around children and pregnant women. The vapor produced by these devices contains nicotine, which is harmful to brain development and fetal development.
Response: As a reminder, not all vapor contains nicotine. Research shows that vaping does affect nicotine levels of bystanders. Strangely, the Oklahoma Tobacco Helpline which is jointly sponsored by the OSDH and the Tobacco Settlement Endowment Trust (TSET)and provides counseling and nicotine replacement products for smoking cessation such as nicotine containing gum and patches, does not preclude pregnant women from using nicotine replacement products. The reason for this is although nicotine poses some risk to the developing fetus, smoking as a delivery system for nicotine is far more dangerous than nicotine alone. If a woman cant or wont quit cold turkey, many physicians encourage the safer option of switching to a safer nicotine delivery system. A significant number of smokers find themselves in a similarly dire situation, where their nicotine delivery system, the cigarette, will shorten their life or kill them but every other method of quitting has failed. These smokers are gaining hope from the growing number of former die-hard smoking peers that have reduced or quit smoking with vapor devices. Vaping is not only a sensible option for these people, it is the only one!

OSDH: Individuals who use e-cigarettes/vapor products to supplement the use of combustible cigarettes are not improving their health and quitting cigarettes completely is the only way to achieve health benefits.
This statement is meant to convey that e-cigarettes are as bad as smoking which is an outright lie. It smacks of propaganda. No one rationally disputes that e-cigarettes are vastly safer than smoking and only the most devious would even try. Supplement means in addition to. The OSDH seems to be alluding to the idea that smokers are using e-cigarettes in addition to their smoking habits. There are no known instances of such practices! There are, however, thousands and thousands of personal accounts and reliable studies which show that smokers reduce cigarette consumption and quit using e-cigarettes. Even more encouraging is a recent study involving hundreds of subjects who expressed no desire to quit that when supplied with a personal vapor device either quit or significantly reduced their consumption of cigarettes. This is lifesaving technology! The American Association of Public Health Physicians (AAPHP) agrees saying that it " favors a 3 permissive approach to e-cigarettes because the possibility exists to save the lives of four million of the eight million current adult American smokers who will otherwise die of a tobacco-

related illness over the next twenty years.

OSDH: E-cigarettes/vapor products have not been adequately tested nor approved as tobacco cessation devices.
Response: Unapproved does not equal unsafe. There are many studies that clearly indicate the safety and effectiveness of vapor devices for smoking cessation. How many approved products can you recall that have turned out later to be deadly? How many potentially life-saving products have not been approved and withheld from the public? The answer is many!

OSDH: Nicotine replacement therapy products approved by the FDA are the only products that contain controlled doses of nicotine and have been tested and regulated for safety and effectiveness.
Response: Pharmaceutical interventions for smoking cessation have a 9 out of 10 failure rate. There is a significant population of smokers for whom none of the traditional methods have worked. The message from our health agency appears to be either you quit the way we want you to quit, or you DIE! Our lives, our health matters and this approach is unacce ptable!

OSDH: More research is needed on the impact of vapor products and how they affect cancer, heart disease, and other long-term health consequences. Caution is advised until further research is conducted on the long-term effects of vapor products.
Response: The World Health Organization projects ONE BILLION will die from smoking in the 21st Century. Pharmaceutical interventions for smoking cessation (such as the nicotine patch, gum, inhaler etc.) have a 9 out of 10 failure rate. For a significant minority of smokers, none of the tradition methods work at all and they will lose years and possibly their lives to the habit of smoking. If there is anyone who believes cigarettes are no more hazardous than e -cigarettes Id recommend a remedial course in basic sciences. For anti-nicotine campaigners who say we need to wait for more research I would point out the way they are proving Nietzsche correct we take on the attributes of our enemies. Cigarette companies spent decades making spurious claims that we need more research before we could move on policy measures, despite the already-existing basis for informed policy measures. They provide very poor role models. --David Sweanor The CDC states that 5, 800 Oklahomans per year will die prematurely due to smoking related illness and the WHO projects 1 Billion lives lost to smoking in the 21st century. Does the OSDH understand that many lifelong smokers cant afford to wait? The scientific evidence is clear and no one disputes the fact that to using noncombustible vapor products is vastly safer than cigarette smoking. What exactly are we waiting for?

My message to anyone who knows a cigarette smoker is to introduce him or her to e cigarettes immediately. --Dr. Elizabeth Whelan
4