Response to ANR fact sheet: Electronic cigarettes and secondary aerosol
This note urges state and local legislatures not to ban e-cigarette use in no-smoking areas. Such a ban will do nothing to protect bystanders. It will do nothing to promote cessation of smoking. It would, however, potentially damage the health of the public by conveying a false impression that e-cigarettes are as hazardous as combustible cigarettes, and, by that means, prevent some inveterate smokers from switching to these far-less-hazardous products.
As a public health physician and long-term supporter of ANR, I am appalled at the inaccurate and distorted presentation of the hazards posed by e-cigarettes to bystanders in indoor environments in this diatribe against e-cigarettes. This paper, unworthy of support by any health-related organization, is based on unfounded speculation, laboratory studies bearing no relationship to real-life exposure, and presentation of the vapor inhaled by e-cigarette users as if it were the vapor in indoor air exhaled by e-cigarette users. This paper does not reference the now-extensive literature documenting real-life exposure to e-cigarettes by both users and bystanders. It does not reference the trace quantities of organic chemicals exhaled by persons who are neither smoking nor vaping. It does not present a single review or case report alleging illness in an e-cigarette user or in a bystander due to use or exposure to exhaled e-cigarette vapor.
If ANR was truly concerned about exposure of bystanders to exhaled nicotine in any form, it could have and should have recommended prohibition of pharmaceutical nicotine vaporizers in no-smoking areas many years ago. The fact that it has not raises serious questions as to why ANR is recommending that e-cigarette use be banned in non-smoking areas at this time.
E-Cigarettes – A Public Health Perspective
ANR , and other opponents of e-cigarettes like to frame the e-cigarette debate in terms of the health of the public v. evil and greedy tobacco companies intent on addicting teens to their deadly products. While socially and politically correct in some public health circles, there a very different public health perspective that should be considered.
Despite decades of tobacco control programming, there are still about 46 million smokers and cigarette smoking causes an estimated 480,000 deaths per year in the United States.  Furthermore, the numbers of smokers and smoking-attributable deaths in the United States has been essentially stable since 2004. , 
Given the 15-20 year delay between initiation of smoking and onset of potentially fatal smoking-attributable illness, the vast majority of the 9,600,000 Americans who will die of a smoking-attributable illness in the next 20 years (480,000 deaths per year x 20 years) are currently adult American Smokers currently over 35 years of age. Tobacco harm reduction, with e-cigarettes as a harm reduction modality, currently appears to be the only feasible policy option likely to substantially reduce tobacco related illness and and death over the next 20 years. A THR initiative, as an addition to current tobacco control programming would consist of informing current smokers who are unable or unwilling to quit that they could reduce their risk of tobacco-attributable illness and death by 98% or better by switching to a smokeless tobacco option or e-cigarettes. A more complete and well referenced discussion of this topic can be found on the R Street web site. 
If the goal of ANR is to reduce tobacco-attributable illness and death, it should carefully consider the potential benefits of e-cigarettes and realistically appraise their potential harms, as compared to the pharmaceutical nicotine inhalers that ANR apparently endorses.
Hazards Posed by Environmental Tobacco Smoke
I, and many other public health physicians, have long supported ANR because of the hazard to bystanders presented by environmental tobacco smoke. Tobacco smoke is a witch’s brew of toxic chemical substances from the incomplete combustion of tobacco.
About 85% of environmental tobacco smoke is sidestream smoke that curls off the end of a cigarette when no-one is puffing on it. E-cigarettes have no sidestream smoke.
ETS increases the risk of lung cancer and other cancers; heart and lung disease; the risk of low birth weight; and is suspected of increasing the risk of birth defects. CDC estimates that approximately 49,000 non-smokers die in the United States from exposure. 
Hazards (if any) Posed by E-cigarettes to Bystanders
E-cigarettes have no products of combustion. Nothing curls off the end of an e-cigarette when no-one is puffing on it. The mainstream vapor exhaled by the user includes only the tiniest traces of chemical contaminants.
A number of studies have been very recently published dealing with the concentration of organic chemicals in exhaled e-cigarette vapor. Basically, these studies show that when the e-cigarette user exhales into a glass tube or similar container, trace quantities of a variety of organic chemicals can be detected, but, when in an 8 cubic meter test chamber or similar room, for a half hour or more, e-cigarette use does not measurably increase the trace quantities of these chemical substances above background levels, while cigarettes cause dramatic rapid increases.6-8 Perhaps the most interesting finding in these studies is that persons not using any form of tobacco routinely exhale trace amounts of acetone, ethane, pentane and isoprene and other endogenous volatile organic compounds. , , , 
Review of Allegations in the ANR February 2014 E-Cigarette Paper 
“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.” This allegation is based on a recently published paper by Fuoco et al consisting of a laboratory analysis of machine-generated mainstream (not exhaled) e-cigarette vapor, with multiple mathematical corrections, bearing no relationship to the vapor that might be exhaled by a real live human e-cigarette user.
“Exposure to fine and ultrafine particles may exacerbate respiratory ailments like asthma, and constrict arteries which could trigger a heart attack.” This is based on a literature review by Grana, et al, speculating on illness and symptoms that might be caused by similar particulate matter far higher in concentration than could ever be expected from inhaled or exhaled e-cigarette vapor.
Regarding “10 chemicals in e-cigarette aerosol” – the data in the Goniewicz paper show the concentrations in indoor air as so small that they are not measurable above baseline. The Goniewicz paper concluded that levels of toxicants were similar to the reference pharmaceutical nicotine inhaler. The Williams paper deals only with vapor as inhaled by the user, with no reference to metals in exhaled vapor.
Regarding propylene glycol – while inhaled e-cigarette vapor can cause throat irritation in e-cigarette users, the tiny amounts of propylene glycol in exhaled vapor is unlikely to be noticed by bystanders. The references quoted to justify this statement reflect industrial concentrations of propylene glycol and consistent long term exposure. The reference quoted relative to degradation of propylene glycol producing small amounts of a carcinogen deals with “heat degradation studies of solar heat transfer fluids.”
The reference to metals in e-cigarette aerosol, as noted above, related only to the vapor inhaled by the user, not exhaled e-cigarette vapor.
The reference to nitrosamines and dietyhylene glycol in e-cigarette vapor are from the same 2009 analysis, reflecting the vapor inhaled by the user, not exhaled vapor, making no comparison to the FDA approved nicotine inhalers, and, in one of 20 samples, detecting a trace of diethylene glycol so small, that the e-cigarette user would have to use the e-cigarette equivalent of 1,500 cigarettes in a single day to reach the minimal toxic dose.
Regarding nicotine exposure – yes, e-cigarettes are designed to deliver nicotine, and traces of nicotine are exhaled. There is no reference to any bystander ever being harmed by such nicotine exposure from cigarettes or e-cigarettes. It is also important to note that nicotine is routinely consumed in trace amounts in tomatoes, eggplants and other vegetables, with no known adverse consequences.
Allegations of respiratory distress and other ill effects are theoretical speculations based on exposures far in excess of those to be expected from e-cigarette use.
In conclusion, there is no public health justification for banning e-cigarette use in no-smoking areas. Such bans will be harmful to the health of the public to the extent that they suggest that e-cigarettes may be as hazardous as combustible cigarettes, and, by that means, inhibit inveterate smokers from switching to these far lower risk nicotine delivery products.
Dr. Joel Nitzkin is public health physician. He has been a local health director, a state health director and President of two national public health organizations.
He has been involved with tobacco control since the late 1970’s. From early 2007 through mid-2010, he served as Co-chair of the Tobacco Control Task Force of the American Association of Public Health Physicians. During that period, when the Tobacco Control Act was making its way through Congress, he, and his AAPHP colleagues decided to do our own independent literature review to determine the best way for the USA to reduce tobacco-attributable addiction, illness and death. It was that literature review that drew our attention to tobacco harm reduction as the most promising of public health interventions, and to e-cigarettes as possibly the most promising of tobacco harm reduction modalities.
The views expressed herein are entirely his own, they do not reflect position statements formally adopted by AAPHP, R Street or any other organization he is affiliated with. Neither Nitzkin nor AAPHP have ever received any financial support from any tobacco, e-cigarette or pharmaceutical enterprise. Dissemination of this statement is supported by the R Street Institute, a Washington-DC based libertarian think tank that respects the role of government in regulating industry to protect health and the environment, but strongly opposes undue governmental interference with market forces. R Street designated tobacco harm reduction as one of their priority issues after FDA attempted to remove e-cigarettes from the market by declaring them to be an unapproved drug-device combination subject to the provisions of the drug law.
Additional bibliographic references dealing with these and other issues are available on request from Dr. Nitzkin at [email protected]
1. Americans for Nonsmokers’ Rights, 2014, Feb, Electronic (e-) Cigarettes and Secondhand Aerosol (Accessed 21 February 2014).
2. Office of the Surgeon General U. The health consequences of smoking – 50 years of progress, 2014.
3. Centers for Disease Control and Prevention, 2013, 1/August, Tobacco-Related Mortality, in CDC Fact Sheet-Tobacco Related Mortality Smoking and Tobacco Use <>.
4. Centers for Disease Control and Prevention, 2008, 14 November, Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses — United States, 2000-2004. Morbidity and Mortality Weekly Report;57(45) <> (Accessed 26 September 2010).
5. Nitzkin JL, 2013, November, R Street Policy Study No. 11: The Promise of e
-Cigarettes for Tobacco Harm Reduction (Accessed 21 February 2014).
6. Schripp T, Markewitz D, Uhde E, Salthammer T. Does e-cigarette consumption cause passive vaping? Indoor Air 2013;23:25-31.
7. Czogala J, Goniewicz M, Fidelus B, Zielinska-Danch W, Travers M, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine & Tobacco Research 2013.
8. Romagna G, Zabarini L, Barbiero L, Bocchietto E, Todeschi S, Caravati E et al. Characterization of chemicals released to the environment by electronic cigarettes use (ClearStream-AIR project): Is passive vaping a reality? 14th Annual Meeting of the Society for Research on Nicotine and Tobacco. Helsinki, Finland, 1/Sep, 2012.
9. Larstad M, Toren K, Blake B, Olin AC. Determination of ethane, pentane and isoprene in exhaled air — effects of breath-holding, flow rate and purified air. Acta Physiol (Oxf) 2007 Jan;189(1):87-9.
10. Smith D, Spanel P, Enderby B, Lenney W, Turner C, Davies J, 2010, Isoprene Levels in the Exhaled Breath of 200 Healthy Pupils Within the Age Range 7-18 Years Studied Using SIFT-MS. Journal of Breath Research;4(1) (Accessed 8Dec2013).
11. King J, Koc H, Unterkofler K, Mochalski P, Kupferthaler AT G, Teschl S et al. Physiological modeling of isoprene dynamics in exhaled breath. J Theor Biol 2010 21/Dec;267(4):626-37.
12. King J, Kupferthaler A, Frauscher B, Hackner H, Unterkofler K, Teschl G et al., 2012, Measurement of Endogenous Acetone and Isoprene in Exhaled Breath During Sleep. Physiol Meas;33(3) (Accessed 8Dec2013).