Dear Louisville Metro Department of Public Health and Wellness:

My name is Dr. Edward Anselm. I am a medical expert currently serving as director for Health Republic Insurance of New Jersey (HRINJ) in addition to my position as assistant professor of medicine at the Icahn School of Medicine at Mount Sinai. I have a 30-year history of tobacco-control advocacy and have run some of the most efficacious smoking cessation programs in our country’s history. Recently, I joined the R Street Institute, a policy center in Washington, D.C., where, as a senior fellow, I am devoted to studying tobacco harm reduction. This is an area I both know well and care deeply about, so accordingly would like to share my thoughts about proposed regulations that would add Hookah and Electronic Cigarettes to the Ordinance on a smoke-free environment.

The 2008 Louisville ordinance on smoke-free environments is evidentially well grounded1 and has positively contributed to the health of thousands of citizens. Since the harm of cigarette smoke extends to people inhabiting the same environment, legislation to safeguard citizens from smoking has been effective in transforming the culture of tobacco use and protecting many from exposure.

However, our careful reading of the Department of Health Website—specifically the fact sheet on e-cigarettes—suggests the proposed revisions to the ordinance are not based on the same level of scientific foundation. The evidence base cited in the fact sheets is incomplete and might predispose the reader to seek a ban on e-cigarette use. In fact, the health effects of passively inhaled vapor from e-cigarettes is unknown. And actually, the health effects of electronic cigarettes on actual smokers have been studied in surveys 2 which reveal only a small proportion of users reporting irritation or dryness. Another study followed a cohort of cigarettes users for two year with the same findings3. In the decade of widespread e-cigarette availability, with tens of millions of users, no clinical syndromes associated with e-cigarette use have been identified.

If there are no clinical syndromes associated with direct use of e-cigarettes, what is the harm from which this ordinance seeks to reduce?

None of the authors investigating e-cigarettes suggest they are completely safe for individual use. What I would like to call your attention to, however, is the fact that all authors are in agreement with the statement that e-cigarettes are substantially safer than smoking traditional cigarettes 4,5.

Most authors share concerns regarding the large number of e-cigarette product types developed in the absence of industry standards. The liquids used to produce vapor are of unknown source, and there are over 8000 different flavor combinations available6. A small number of studies have compared the effects of vapor from selected brands to that of traditional (combusted) cigarettes. In most of these papers the concentration of toxins found was lower in e-cigarettes. (C.f. the Goniewicz study, considered to be the most comprehensive on the subject.) 7 The current consensus is that many of the disease producing toxins resulting from combusted smoke are absent in e-cigarettes. Moreover, when toxic chemicals are present, they are found in substantially lower concentrations than in combusted smoke4. In additional, albeit important, consideration regards the harm reduction value of e-cigarettes. Strikingly, numerous studies show that up to 30% of smokers adopt e-cigarettes completely and another 20% reduce their smoking habits in absolute terms 8-12.

Put another way, if you want to reduce tobacco harm, efforts to curb the e-cigarette alternative is not the way to do it.

In summary, I respectfully request the commission reexamine the evidence on harm from e-cigarettes.


Dr. Edward Anselm

  1. Prevention. CfDCa. Best Practices for Comprehensive Tobacco Control Programs—2014. In: U.S. Department of Health and Human Services, ed. Atlanta: U.S. Department of Health and Human Services, : Centers for Disease Control and Prevention, ; 2014.
  2. Farsalinos KE, Poulas K, Voudris V, Le Houezec J. Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries. Addiction. 2016.
  3. Manzoli L, Flacco ME, Ferrante M, et al. Cohort study of electronic cigarette use: effectiveness and safety at 24 months. Tobacco Control. 2016.
  4. Nutt DJ, Phillips LD, Balfour D, et al. Estimating the harms of nicotine-containing products using the MCDA approach. European addiction research. 2014;20(5):218-225.
  5. Physicians. RCo. Nicotine without smoke: Tobacco harm reduction. London, England: Royal College of Physicans; 2016: file:///C:/Users/User/Downloads/Nicotine%20without%20smoke_0%20(5).pdf. Accessed 5/2/2016.
  6. Grana R, Benowitz N, Glantz SA. E-cigarettes a scientific review. Circulation. 2014;129(19):1972-1986.
  7. Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco control. 2014;23(2):133-139.
  8. McNeil A, et. al,. E-cigarettes: an evidence update. London, England: GOV.UK; 2015.
  9. Phillips CV. CASAA ecig survey results. Anti-THR Lies and related topics. Vol 2016.
  10. Malas M, van der Tempel J, Schwartz R, et al. Electronic Cigarettes for Smoking Cessation: A Systematic Review. Nicotine & Tobacco Research. 2016:ntw119.
  11. Hartmann‐Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. The Cochrane Library. 2016.
  12. Hajek P, McRobbie H, Bullen C. E-cigarettes and smoking cessation. The Lancet Respiratory Medicine. 2016.

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