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Passive Vaping

Exposure to secondhand aerosol of electronic cigarettes in indoor settings

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Measurements of electronic cigarette-generated particles for the evaluation of lung cancer risk of active and passive users

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Vapers beware: 10 things to know about e-cigarettes

With catchy names like Smurf Cake and Unicorn Puke and sweet flavors like bubble gum and strawberry, electronic cigarettes may have special appeal to young people, but that doesn’t mean they are safe.

Evidence is mounting that e-cigarettes are exposing a new generation to nicotine addiction and may be leading users toward a cigarette habit. As a result, the U.S. surgeon general last month issued a report declaring youth e-cigarette use “a major public health concern.”

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said Surgeon General Vivek Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The battery-powered devices heat a liquid typically containing nicotine mixed with the chemicals propylene glycol and glycerin as well as flavorings to deliver an aerosol inhaled by the user. While e-cigarettes deliver nicotine without the tar and smoke of traditional tobacco cigarettes, they still are considered tobacco products.

But their healthy halo has helped propel their popularity: E-cigarettes are now so popular that more American youth vape than smoke cigarettes. In just a decade, e-cigarettes have become a multibillion-dollar business led by multinational tobacco companies with outlets not just online but everywhere from vape shops to convenience stores and retail giants like Wal-Mart.

Ads tout them as a cool, harmless alternative to cigarettes. E-cigarette users, or vapers, have contests to see who can blow the largest cloud of vapor.

But there’s more to e-cigarettes than meets the eye. The surgeon general’s report aligns with increasing scrutiny of e-cigarettes, from new regulations to a growing body of research into health effects.

Here are 10 things to know about e-cigarettes:

E-cigarettes contain nicotine

E-cigarettes contain nicotine, which is addictive and can harm the developing adolescent brain, said UC San Francisco professor of medicine Stanton Glantz.

A lot of the kids who take up vaping are at low risk for smoking, but once they start using e-cigarettes, they are three to four times more likely to start using cigarettes, Glantz said.

“The biggest health concern with e-cigarettes is they are prolonging and expanding the tobacco industry,” Glantz said.

Glantz, director of UCSF’s Center for Tobacco Control Research and Education, said he was initially neutral on e-cigarettes, but now finds them concerning. Among other hazards, e-cigarettes produce ultrafine particles than can trigger inflammatory problems and lead to heart and lung disease.

“The data is just becoming overwhelming,” Glantz said.

E-cigarettes expose people to more than ‘harmless water vapor’

E-cigarettes are billed as producing “harmless water vapor,” but, strictly speaking, the vapor produced when users exhale is actually an aerosol that contains a mixture of nicotine, flavorings and other ingredients that can be toxic.

Stanford University pediatrics professor Bonnie Halpern-Felsher has studied young people’s perceptions of e-cigarettes. In September, she launched a free, downloadable youth tobacco prevention toolkit with an e-cigarette module, funded by the UC Tobacco-Related Disease Research Program (TRDRP) and the California Department of Education.

“Youth are definitely using e-cigarettes because they think they are cool,” Halpern-Felsher said. “Adolescents and young adults don’t know a lot about e-cigarettes. They think it’s just water or water vapor. They don’t understand it’s an aerosol. They don’t understand that e-cigarettes can have nicotine. They don’t understand that flavorants themselves can be harmful.”

The flavors can be toxic

More than 7,000 varieties of flavored e-cigarettes are on the market.

UC Riverside professor of cell biology Prue Talbot screened the cytotoxicity (quality of being toxic to cells) of 36 refill fluids and found that some were highly toxic. The most cytotoxic flavor, Cinnamon Ceylon, contained a chemical called cinnamaldehyde, which gives cinnamon its flavor and whose side effects may include coughing and sore throats. Talbot has been studying more flavors and is building a database to help determine the most dangerous ones.

“Flavors are something that could be potentially regulated,” Talbot said.

Vaping has secondhand and thirdhand effects

Unlike cigarettes, which emit smoke from the lit end, e-cigarettes don’t produce sidestream emissions between puffs, but they still generate secondhand and thirdhand effects when users exhale the mainstream vapor.

In a TRDRP-funded study, Berkeley Lab researcher Hugo Destaillats led a team that found 31 chemicals that include several toxicants at significant levels in e-cigarette vapor. The most toxic chemicals included acrolein, a severe eye and respiratory irritant; and formaldehyde, an irritant and probable carcinogen.

Emissions varied by type of device and voltage.

“The way you heat the liquid drastically determines if you produce a lot of compounds or just a few,” Destaillats said. “As you increase the voltage, toxic byproduct concentrations increase exponentially.”

The batteries can explode

There were 134 reports of e-cigarette batteries overheating, catching fire or exploding between 2009 and January 2016, according to the Food and Drug Administration, which will host a public workshop in April to gather information about e-cigarette battery safety concerns.

E-cigarette batteries “can explode without notice,” Talbot said. “People can be quite severely injured.”

E-liquids are poisonous if swallowed

Calls to poison control centers about e-cigarette exposure in young children have skyrocketed nationally in recent years. In California, the number of calls involving e-cigarettes increased from 19 in 2012 to 243 in 2014, according to the UC-administered California Poison Control System. More than 60 percent of those e-cigarette calls were related to nicotine poisoning in children 5 and under.

E-cigarettes show mixed results in helping smokers quit

While some people have quit smoking with e-cigarettes, on average, adult smokers who use e-cigarettes are about 30 percent less likely to stop smoking cigarettes, Glantz said. Also, e-cigarettes are associated with more, not less, cigarette smoking among adolescents.

“If you are a middle-aged person who has been smoking for 20 years, maybe it is good to switch to e-cigarettes,” Destaillats said. “But if you are a teenager and never have smoked, then it is not a good idea to use e-cigarettes.”

The minimum age has risen

In June, California became the nation’s second state, following Hawaii, to raise the minimum age for tobacco sales to 21, and for the first time added e-cigarettes to the definition of tobacco products. In August, the FDA extended its tobacco oversight to e-cigarettes, banning sales to those under 18.

“It sends a message to youth that e-cigarettes are in the same category of all tobacco products,” Halpern-Felsher said.

E-cigarettes will be taxed

Under Proposition 56, the tobacco tax passed by California voters in November, the state will tax e-cigarettes for the first time, starting April 1. It’s estimated that the price of a typical 30-milliliter bottle of e-liquid could increase to about $30 from $20.

“Anytime you increase the price, people buy less,” Glantz said.

The tax revenue will enhance education efforts by boosting funding for the state Tobacco Control Program. The surgeon general’s report also will make it easier for states to integrate e-cigarettes into tobacco education campaigns and could lead to more regulations, Glantz said.

E-cigarettes may be safer than cigarettes, but unknown risks remain

Expect more information to emerge about e-cigarettes as studies examine long-term effects.

“It’s often assumed that e-cigarettes are safer than cigarettes, but that could be an incorrect assumption,” Talbot said. “We don’t yet know the long-term health effects of e-cigarettes.”

Decades of research have helped scientists determine that cigarette smoke creates more than 7,000 chemicals, at least 69 of which are known to cause cancer and many of which are poisonous.

So, while e-cigarettes deliver fewer cancer-causing chemicals than cigarettes, research has yet to reveal how e-cigarettes fully impact heart and lung health and their cancer-causing potential, Glantz said.

He estimates that e-cigarettes are about one-third to one-half as dangerous as cigarettes.

In other words, they are still plenty dangerous.

“Regular cigarettes are super unhealthy,” Destaillats said. “E-cigarettes are just unhealthy.”

Ban e-cigarettes from public places, say world health chiefs

Britain is told to outlaw the increasingly popular vaping devices from schools, hospitals and buses amid health concerns

• The WHO is calling for countries to look at a ban due to ‘passive vaping’
• It has been linked to lung damage, heart complications and stillbirths
• Move echoes call from the BMA, which said e-cigarettes should be banned
• WHO’s stance will be controversial among many, including British medics

Britain is being asked by the world’s leading health watchdogs to consider banning electronic cigarettes from public places.

Countries could ban e-cigarettes from all public places where smoking is not allowed, a World Health Organisation report says.

Such a ban would outlaw the increasingly popular vaping devices from schools, hospitals and public transport in the same way as tobacco.

The WHO is calling on countries to look at this because of the dangers of ‘passive vaping’, which growing evidence has linked to lung damage, heart complications and stillbirth in pregnant women.

The move echoes calls from the BMA, which says e-cigarettes should be banned from pubs and restaurants because of just such dangers. The WHO is also supporting potential cigarette-style health warnings about the chemicals e-cigarettes include and information on the danger of addiction.

Its advice, issued before a major meeting on tobacco control in India next week, is expected to stoke a row between health experts.

There is some evidence linking e-cigarettes to cancer and fears they act as a gateway to smoking tobacco.

But British doctors are already using e-cigarettes to help people quit tobacco, with support from Public Health England, if the devices are licensed, to prescribe them on the NHS.

The WHO’s report sums up the latest scientific evidence ahead of next week’s meeting of 180 countries signed up to the Framework Convention on Tobacco Control. Dr Vera Luiza da Costa e Silva, head of the WHO convention secretariat, said: ‘So far there is a clear understanding that e-cigarettes should be regulated. They should not be promoted among young people and pregnant women and other specific groups. They should not be promoted widely – there should be restrictions and regulations.’

The WHO’s stance will be controversial among those – including British medics – who see e-cigarettes as helpful in getting smokers to quit.

A recent study found around 18,000 people in England last year may have given up cigarettes by vaping, which provides nicotine without the tobacco linked to lung cancer.

But the WHO says this is undermined by the number of young people being ‘recruited’ into nicotine dependency by taking up e-cigarettes. It suggests countries consider banning the flavouring of e-cigarettes whose bubblegum and fruit varieties have raised concerns they may be appealing to children. It also says they should not be sold or advertised to young people.

The WHO also highlights health fears over liquid nicotine vapour. It says metals, including lead, chromium and nickel, have been found in e-cigarettes at higher levels than ordinary cigarettes, while nicotine itself may act as a ‘tumour promoter’ in people with cancer, or cause heart disease.

But Professor Kevin Fenton, national director of health and wellbeing at Public Health England, said it will continue to monitor the evidence.

He added: ‘The evidence remains clear, with PHE’s most recent review and the Royal College of Physicians both finding that while not completely risk-free, vaping carries a fraction of the risk of smoking – around 95% less harmful.

‘The real concern is that smokers increasingly believe the inaccurate reports that vaping is as dangerous as smoking and are more likely to continue to smoke.’

Flavoring Compounds Dominate Toxic Aldehyde Production during E‑Cigarette Vaping

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Doctors call for e-cigarette ban in public places over ‘passive vaping’ fears

Electronic cigarettes should be banned in public places to avoid the risk of “passive vaping”, doctors have warned.

The British Medical Association (BMA) yesterday called for e-cigarettes to be outlawed in bars, cafes, restaurants, museums and schools.

Glasgow public health consultant Dr Iain Kennedy warned there was evidence of second-hand vaping, particularly at people’s homes.

He claimed the activity, judged to be around 95 per cent safer than smoking tobacco, still polluted the air with harmful chemicals.

Dr Kennedy told the association’s annual meeting in Belfast: “There is growing evidence that passive vaping happens, particularly based around testing nicotine levels in households.

“What we don’t know yet is what the precise mechanisms of that are, what long-term harm there is.

“This is cutting edge research, with findings being published at the moment.”

But the BMA’s position put them at odds with Public Health England, which has warned that banning e-cigarettes would damage people’s chances of quitting smoking.

The organisation’s director of drugs, alcohol and tobacco, Rosanna O’Connor, said: “Vaping is not the same as smoking.

“Second-hand smoke is harmful to health but there is no evidence that e-cigarette vapour carries the same harms.

“In fact a ban on using e-cigarettes in public places could be damaging, as it may put off smokers from using e-cigarettes to help them quit.”

Exhaled aerosol particles e-cigs & cigarettes

Exposure to e-cigarettes increases by 1,500% among children

The frequency at which young children are exposed to e-cigarettes and liquid nicotine has increased dramatically between 2012 and 2015, according to recent research in Pediatrics.

“Despite the rapid increases in e-cigarette use and pediatric exposures, an analysis that focuses exclusively and comprehensively on the trends associated with exposures among young children nationally has not been published,” Gary A. Smith, MD, DrPH, of the Center for Injury Research and Policy at The Ohio State University College of Medicine, and colleagues wrote. “This is the first comprehensive multiyear study of e-cigarette, nicotine, and tobacco exposures among young children using a national database.”

The researchers utilized the National Poison Data System to analyze exposures associated with nicotine and tobacco products among children aged younger than 6 years. The dataset included all calls made to U.S. poison control centers from January 2012 through April 2015. The researchers grouped exposures into four groups: e-cigarettes, cigarettes, tobacco products and unknown products.

Overall, 29,141 calls — averaging 729 exposures per month — were made to poison control centers regarding nicotine-related products for children in the study group. Results showed that the monthly amount of e-cigarette exposures increased 1,492.9% during the study period. The researchers reported that children aged younger than 2 years accounted for 44.1% of e-cigarette exposures and 91.6% of cigarette exposures. Exposure to e-cigarettes represented 14.2% of all tobacco-related exposures among children aged younger than 6 years.

Smith and colleagues observed that children exposed to e-cigarettes had 5.2 times greater risk for admittance to a health care facility and a 2.6-fold greater risk for experiencing a severe outcome vs. children exposed to cigarettes.

“Swift government action is needed to regulate these products to help prevent child poisoning,” Smith and colleagues wrote. “Prevention strategies include public education; appropriate product storage and use away from children; warning labels; and modifications of e-cigarette devices, e-liquid, and e-liquid containers and packaging to make them less appealing and accessible to children.” – by David Costill

Disclosure: The researchers report no relevant financial disclosures.

10 common questions about e-cigarettes answered

1. Are e-cigarettes safer than smoking?

Dr McEwen: Yes. Experts think that e-cigarettes are, based on what we know so far, much safer than cigarettes. Smoking is associated with a number of very serious health risks to both the smoker and to others around them. So switching from tobacco to e-cigarettes substantially reduces a major health risk.

2. Is nicotine dangerous?

Dr McEwen: Nicotine doesn’t cause smoking-related diseases, such as cancers and heart disease, but it is addictive. However, there’s a common misconception that you can overdose on nicotine using e-cigarettes. But you are in no danger of poisoning yourself, nor have there been any cases of overdose from inhaling the nicotine-containing fluid that an e-cigarette vaporises, known as e-liquid. So you can use your e-cigarette as often as you need to help manage nicotine withdrawal and urges to smoke.

Much the same as with Nicotine Replacement Therapy, if you do have more nicotine than you’re used to, then you might feel a little nauseous or lightheaded, both of which pass quickly. If this happens, just reduce the level of nicotine in the e-liquid that you buy, or use the e-cigarette less.

3. Do e-cigarettes produce harmful chemicals or blow up?

Dr McEwen: Some studies have found chemicals in e-cigarette vapour that are known to cause health problems. But these studies have tended to use artificial conditions, and when good quality e-cigarettes are used normally (e.g. not overheated), there are far fewer harmful chemicals present in the vapour than in tobacco smoke. If the e-liquid is being overheated it tends to produce an acrid, unpleasant taste – you’ll know if this happens.

As with any rechargeable device, such as mobile phones and laptops, it’s important to charge e-cigarettes with the right charger, and don’t leave it unattended while charging. Ensure that you buy from reputable suppliers and avoid generic charging equipment. There have been reported cases of e-cigarettes causing fires, but far fewer than the number caused by cigarettes, which are the most common cause of lethal house fires.

4. Is it OK to smoke and vape at the same time?

Dr McEwen: There’s no evidence that smoking cigarettes and vaping at the same time is any worse than just smoking tobacco. But the greatest health benefits are seen when people stop smoking tobacco completely, so quitting smoking should be the goal.

Some people manage to switch completely to vaping quickly, while others take a little time. You may have to try a number of different e-cigarettes and e-liquids before you find one that helps you to stop smoking completely, but this is quite normal.

5. Can I use an e-cigarette in the Stop Smoking Services?

Dr McEwen: Yes. If you choose to use an e-cigarette, Stop Smoking Services can still support you in your quit attempt – and these services the most effective way to quit.

Their trained stop smoking practitioners provide behavioural support, advice on what might be the best way for you to stop and access to approved stop smoking medications.

6. Which e-cigarette should I start with?

Dr McEwen: This is very much a personal choice. The refillable tank system e-cigarettes might take a bit of getting used to, but they allow you to use more flavours, and generally deliver more nicotine than e-cigarettes that look like tobacco cigarettes. Users tend to say these types are more satisfying. Specialist e-cigarette retailers can give you advice, and you can also chat to other e-cigarette users on a range of internet forums.

How much nicotine you need will depend upon how much nicotine you’re used to getting from your cigarettes. And, of course, how much nicotine you get from your e-liquid will depend upon the type of e-cigarette that you use and how you use it. As a rough guide, most 20-a-day smokers find that 18mg/ml (1.8 per cent) nicotine is sufficient, so you could start with this and see how you get on.

7. How should I use my e-cigarette to help me to stop smoking?

Dr McEwen: Using an e-cigarette is different from smoking a cigarette. It usually involves taking slower and longer puffs over a longer period of time. This is because e-cigarettes heat a coil in a liquid (think of a kettle). You may find you need to take a few puffs on an e-cigarette at times when you wouldn’t have smoked, but this is nothing to worry about, and the way you use your e-cigarette will develop over time. It’s not like a cigarette, which you smoke from start to finish. With an e-cigarette you can use it once or twice, and then put it away. If you find you’ve got it in your mouth all the time, you might need to use a stronger e-liquid.

If you get a bit of a cough when you use your e-cigarette, this isn’t unusual and it might help to switch from an e-liquid with a high proportion of propylene glycol to one with more vegetable glycol, which can be more soothing.

8. Will e-cigarettes be cheaper for me than smoking?

Dr McEwen: Yes, and you’ll notice savings very quickly compared with buying cigarettes. A starter kit for the tank-style devices can range from £20-70. You’ll then only need to replace the atomiser (heating coil or ‘head’) occasionally for a couple of pounds and, more regularly, buy your e-liquid, which can start at £3.00 for 10 ml. How often you need to change the atomiser will depend on how you use the device, but typically it’ll be around every two weeks or when you get a ‘burnt’ taste or low vapour production.

9. Can I use e-cigarettes in places where I can’t smoke?

Dr McEwen: There are no laws preventing or restricting where you can use e-cigarettes. Some places, such as some sports stadiums and most airports, do not allow vaping while others do. If there are no signs indicating this then you should always ask. But it helps to be respectful when using e-cigarettes around others, especially non-smokers.

10. Is second-hand vapour from e-cigarettes dangerous? How can I protect my children?

Dr McEwen: Unlike second-hand smoke from cigarettes – which is known to cause cancer – there’s no evidence that second-hand e-cigarette vapour is dangerous to others. Some studies have found traces of toxic chemicals in second-hand vapour, but at such low levels that they’re not harmful to those around you. E-cigarettes aren’t recommended for use by non-smokers and children.

In order to prevent accidental poisoning, for example by young children drinking e-liquids, you should store your e-cigarettes and liquids away safely, just as you would with household cleaning products and medicines.

The National Centre for Smoking Cessation and Training trains stop smoking practitioners to deliver effective support to people wanting to move away from tobacco.

They’ve developed a briefing to support local Stop Smoking Services to incorporate e-cigarettes into their everyday practice.

Particulate Matter from Electronic Cigarettes and Conventional Cigarettes

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