Loading...
HomeMy WebLinkAboutCOM 1091.019 2012-2014-4 Of H ?yam DRU MAMO KANUHA Council Member District7, Central Kona �tE•os'N'.P PHONE: (808) 323 -4267 FAX: (808) 323 -4786 EMAIL: dru.kanuha(u�haivaiicounn,.gov HAWAII COUNTY COUNCIL West Hawaii Civic Center 74 -5044 Ane Keohokalole Highway, Kailua -Kona, Hawaii 96740 Date: October 29, 2014 TO: J Yoshimoto, Chair And Members of the Hawaii County Council FROM: Dru Mamo Kanuha, District 7 Council Member MVkk---- a n —0 Z tV W v RE: Additional Information Related to Bill 302, Prohibition of Smoking In Certain Places & Use of Electronic Smoking Devices Attached is additional information related to Bill 302, Prohibition of Smoking In Certain Places & Use of Electronic Smoking Devices. Mahalo, DK /lw xc: Laura Murashige, Executive Assistant to the Chair Earlanne Leslie, Special Assistant to the Chair Donna Goodenow, Council Services Jeannette Aiello, Committee Services Nora Avenue, Committee Services Hal 'l"ai `i County is 6111 Equal Opportunity Provider and Employer cs D C-, Comm. log j 9 Ref. To. G, Ref. Date 6 201 1. Electronic Smoking Devices Fact Sheet Source: Coalition for Tobacco -Free Hawaii 2. The Hazards of E- Cigarettes Source: American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) Journal 3. Tobacco Fact Sheet — Electronic Cigarettes Source: Legacy for Health 4. Electronic Cigarettes and Secondhand Aerosol Source: Americans for Nonsmokers Rights 5. Position Statement on E- Cigarettes Source: Partnership for Prevention 6. Tobacco's Dirty Tricks Source: American for Nonsmokers Rights 7. U.S, State and Local Laws Regulating Use of E- Cigarettes Source: American Nonsmokers Rights Foundation 8. Position Statement on E- Cigarettes Source: Forum of International Respiratory Societies 9. Local, County, State and International Laws and Policies on E- Cigarettes Source: Global Advisors Smokefree Policy (GASP) 10. News Release — American Association of Poison Control Centers 11. State Story — Hawai`i State Restrictions on E- Cigarette Sales to Youth Source: Association of State and Territorial Health Officials 2014 12. Consumer Updates on E- Cigarettes Source: FDA 13. DAG's Memo Prohibiting E- Cigarettes in DAGS Buildings Statewide 14. Testimonies 15. News articles on other cities banning E- cigarettes in public places 16. E- Cigarettes and Shaved Ice Flyer C 0 A L I i IL-) N FOR A TOBACCO- FREE HAWAII] Facts about Electronic Smoking Devices Description: Electronic smoking devices (ESDs) are any electronic product that can be used to simulate smoking in the delivery of nicotine or other substances to the person inhaling from the device. There are a variety of devices which include but are not limited to: electronic cigarette, electronic cigar, electronic cigarillo, electronic pipe, e- hookah, vape pens, refillable tank -like or personal vaporizers and any cartridge or other component of the electronic smoking device. These are devices that heat a solution (nicotine and other additives) producing an aerosol that is inhaled without combustion. ESDs vary in quality, safety, size, and efficiency of nicotine delivery.' ESDs are not regulated by the government at all. ESD manufacturers are not required to disclose what chemicals are in their products, where they are produced, how they are made, or the potential health risks they pose. Though there are many unknowns about ESD's, the evidence and research are growing. What is clear is that health researchers and experts do know that ESD's are not safe or harmless. 2 What is exhaled is not a water vapor. The aerosol is a mixture of nicotine, tiny particles of metals, and some of the same harmful toxic chemicals found in secondhand smoke. 3 Contrary to popular belief, there is no conclusive scientific evidence that ESDs are an effective tool in helping people stop using cigarettes. 4 Hawaii County Bill 302 intent is to integrate electronic smoking devices (ESD's) in to all Hawaii County Smoke - Free Laws. We believe that shared air in all public places should be free of all toxic pollutants including cigarette smoke and ESD aerosol. Bill 302 focuses only on the public's health and safety through — Precaution, Prevention and Pro - action: PRECAUTION: Protecting innocent bystanders from the chemicals released in the aerosol of ESDs: • ESDs do not just emit "harmless water vapor." Secondhand ESD aerosol (incorrectly called vapor by the industry) contains nicotine, ultrafine particles and low levels of toxins that are known to cause cancer. 4 • ESDs contain harmful chemicals found similarly in regular cigarettes, such as nicotine, formaldehyde, and lead.' • Long term health effects on non - smokers are unclear because ESDs have only been on the market for the past 10 years, however science and research on the negative consequences is mounting.1 • American Association of Poison Control Centers reported a 219% increase in poisonings from nicotine over a recent 1 year span. This year there have already been 3,041 calls nationwide on ESDs and nicotine. More than half of these reported exposures have occurred in children under 6 years of age. Hawaii Poison Control Center reported a rise in calls about nicotine poisoning - zero in 2011 to 22 in 2013.6 ' Legacy Tobacco Fact Sheet - Electronic Cigarettes, www,legacyforHealth.org, Revised May 2014 Accessed 10/17/2014. ' California Tobacco Control Program: http: / /www.tobaccofreeca.org /smoking- problem /e- cigarettes/ accessed 10/17/2014 Offerman, R. "The Hazards of E- Cigarettes." ASHRAE Journal, June 2014. Goniewicz, M.L.; Knysak, 1.; Gawron, M.; Kosmider, L.; Sobczak, A., Kurek, J.; Prokopowicz, A.; Jablonska - Czapla, M.; Rosik - Dulewska, C.; Havel, C.; Jacob, P.; Benowitz, N., "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes," Tobacco Control, March 6, 2013. And Schripp, T., et al., Does e- cigarette consumption cause passive vaping? Indoor Air, 2012. 23(1): p. 25 -31 American Nonsmokers' Rights Foundation. Electronic Cigarettes http: / /www.no- smoke.org /learnmore.php ?id =645 Accessed 10/17/2014 Williams, M., et al., Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One, 2013. 8(3): p. e57987. Offerman, FJ. "The Hazards of E- Cigarettes." ASHRAE Journal, June 2014. Goniewicz, M.L.; Knysak, J.; Gawron, M.; Kosmider, L.; Sobczak, A.; Kurek, J.; Prokopowicz, A.; Jablonska- Czapla, M.; Rosik - Dulewska, C.; Havel, C.; Jacob, P.; Benowitz, N., "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes," Tobacco Control, March 6, 2013, And, Schripp, T., et al., Does e- cigarette consumption cause passive vaping? Indoor Air, 2012. 23(1): p. 25 -31. 6American Association of Poison Control Centers: http: / /www.aapcc.org /alerts /e- cigarettes/ and Hawaii Poison Center — Rise in Child Poisonings http / /www.kitv.com/ news / rise -in- child- poisonings- from - liquid- nicotine /28308164 Accessed 10/22/2014. October 27, 2014 1 / C O A L I A ION FOR A „� V TOBACCO- FREE HAWAII PREVENTION of illness and disease for innocent bystanders: • Innocent bystanders exposed to ESD ,aerosol are found to absorb nicotine at similar to higher levels as passive smokers.' • Persons with breathing disabilities may have compromised lung function when exposed to the ESD aerosol. Short term exposure causes eye, throat, and airway irritation. Long term exposure causes asthma attacks.$ • A public place or workplace that permits the usage of ESDs may be subject to a violation of the Americans with Disabilities Act Amendment Act. of 2009. 9 • There has been little research into the emissions of the flavor additives in ESDs. Favorants, like diacetal and proplylene glycol are FDA GRAS (Generally Recognized as Safe) for food additives, however the form of ingestion changes the effect on the human body (i.e. swallowed versus inhaled). Once heated, these become airborne respiratory irritants, causing upper respiratory irritation to people around the user." • If left as litter in county parks and beaches, ESD containers and other waste could potentially poison children and animals. E- liquids are poisonou! if swallowed. Small children or pets can become seriously ill or die if they swallow e- liquid. It is also harmful if e- liquids get on skin or in eyes. The small ESD batteries are also poisonous if swallowed." • Nicotine is derived from tobacco and has psychoactive and physiological effects. Nicotine can be harmful to those with cardiovascular diseases arid diabetes or other chronic medical illnesses. Nicotine is a potent poison when mishandled, ingested or absorbed through the skin. It is known to cause birth defects during pregnancy and affects the developing; brain so should not be used by youth." • There are no long -term studies that show using ESD's help people to quit smoking. However, studies show that e- cigarettes do not help people quit smoking cigarettes .13 Instead, many people end up using both products (dual use), which keeps thern at high risk for nicotine poisoning and developing chronic diseases. The tobacco industry is forbidden from claiming that ESD can help people quit smoking because the products are not FDA approved for this purpose. 14 PRO - ACTION — Taking action now! Protect the public's health from the negative health effects of secondhand ESD smoke. • The US Environment Protection Agercy determined that outdoor secondhand smoke can be just as dangerous as indoors. 1s 7 Cigarettes vs. e- cigarettes: Passive exposure at home measured by mean of airborne marker and biomarkers, Montse Balbe, lose M Martinez- Sanchez, et.al. Environmental Research, Vol 135:76 -80Nov 2014. 1 Offerman, Fl. "The Hazards of E-Cigarettes. " ASh RAE Journal, June 2014. Wieslander, G; Norbdck, D; Lindgren, T. "Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects." Occupational and Environmental Medicine 58:10 649 -655, 2001. And Choi, H; Schrnidbouer,N; SpenglerJ, Bornehog, C., "Sources of Propylene Glycol and Glycol Ethers in Air at Home," International Journal of Environmental Research and Public Health 7(12): 4213 -4237, December 2010. 'Americans Disabilities Act: http: / /www.nigasp.oig/wp- content /uploads /2014 /05 /E -Cigs White Paper.pdf 10 Offermon, Fl. "The Hazards of E- Cigarettes. "ASHRAEJournol, June 2014. 11 Cobb, N.K. and D.B. Abrams, E- cigarette or drug- delivery device? Regulating novel nicotine products. N Engl J Med, 2011. 365(3): p. 193 -5. Cantrell, F.L., Adverse Effects of e- Cicarette Exposures. J Community Health, 2014. 39(3): p. 614 -6 12 Legacy Tobacco Fact Sheet - Electronic Cigarettes, www.legacvforHealth.org, Revised May 2014 13 Dutra, L.M. and S.A. Glantz, Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents: A Cross - sectional Study. JAMA Pediatr, 2014. And World Health Organization, Marketers of Electronic Cigarettes Should Halt Unproven Therapy Claims. September 19, 2008. 14 Pope, C.A., 3rd, et al., Cardiovascular mortality and exposure to airborne fine particulate matter and cigarette smoke: shape of the exposure- response relationship. Circulation, 2009. 120(11): p. 941 -8. Barnoya, J. and S.A. Glantz, Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation, 2005. 111(20): p. 2684 -98. is Americans for Non - Smokers' Rights Foundatior — What to Expect from The Tobacco Industry, http://no smoke.org /pdf /whattoexpect.pdf Accessed 10/17/2014. October 27, 2014 2 C / C 0A L I I ION FOR .A TOBACCO -FREE 111WAI`I • It is better to be conservative when it comes to exposure of ESD aerosol to innocent bystanders and prohibit use until proven otherwise.16 There is growing evidence on the potential health risks posed by the use of ESD products, both to the user and the people around them. • In 2013, the Centers for Disease Control and Prevention found more than a quarter million middle and high school students, who had never used regular cigarettes before, had experimented and /or used e- cigarettes, which is a three -fold increase since 2011. 17 • As of April 29, 2014, three states (North Dakota, New Jersey, and Utah) and 172 local governments have included ESDs in their indoor air laws and smoking bans. 1$19 • More cities and counties are increasingly banning ESDs: In October 2014, Santa Monica, CA and Louisville, CO, City Councils unanimously passed ordinances amending the cities' municipal code to ban the use of electronic smoking devices in public places, restricting the practice in the same manner as tobacco cigarettes. These bans focused on potential health risks of e- cigarette vapor and the undesired exposure of youth to behaviors that might encourage smoking. 20 municipalities, including Chicago, New York City and Los Angeles banned ESD in public places and nine of them included ESD ban in outdoor areas such as parks, recreation facilities and where children are present. 20 AWARENESS - Big Tobacco is resurrecting their old campaigns! The Big Tobacco Companies are rapidly buying up ESD companies and some ESDs are manufactured by tobacco companies like Philip Morris, R.J. Reynolds, and Lorillard. The tobacco industry has deliberately misled the public on the risks of smoking cigarettes and are using the same tactics from their cigarette lobbying years ago to divert attention away from the health hazards and now has the ESD small business owners trained to use them. Some of these tactics include: • Diverting the policy debate away from health • Economic scare info — sales, jobs, tourism • Health scare tactics: "Quit or Die" argument • Attacks on science • Litigation • Electoral activity • Individual rights/ anti - bureaucracy /anti- government21 "Despite the tobacco industry's superior financial resources, enactment of a specific local ordinance depends not on the tobacco industry but on how seriously the health advocates mobilize in support of the legislation. When the health community makes a serious commitment of time and resources, it wins, but when the health community fails to make such a commitment, the tobacco industry prevails, more by default than because it has superior financial resources." 22 16 GASP White Paper on Electronic Smoking Devices, http: / /www.njgasp.org /wp- content / uploads /2014 /05 /E- Cigs_White_Paper.pdf Accessed 09/2014. 17 Berg, C.J.; Haardoerfer, R.; Escoffery, C.; Zheng, P.; Kegler, M., Nicotine and Tobacco Research [Epub ahead of print], June 20, 2014. 18 GASP White Paper on Electronic Smoking Devices, http: / /www.njgasp.org /wp- content / uploads /2014 /05 /E- Cigs_White_Paper.pdf Accessed 09/2014 19 American Nonsmokers' Rights Foundation. U.S. State and Local Laws Regulating Use of Electronic Cigarettes. http: / /www.no- smoke.org /pdf /ecigslaws.pdf. Accessed May 13, 2014 20 GASP White Paper on Electronic Smoking Devices, http: / /www.njgasp.org /wp- content / uploads /2014 /05 /E- Cigs_White_Paper.pdf Accessed 09/2014 21 Americans for Non - Smokers' Rights Foundation — What to Expect from The Tobacco Industry, http://no smoke.org /pdf /`whattoexpect.pdf /pdf /`whattoexpect.pdf Accessed 10/17/2014 22 Samuels, S and Glantz S. "The Politics of Local Tobacco Control," Journal of the American Medical Association, October 16, 1991 October 27, 2014 3 COLUMN IA0 APP1ICA1IONS This article was published in ASHRAE Journal, June 2014. Copyright 2014 ASHRAE. Posted at www.ashrae.org. This article may not be copied and /or distributed electronically or in paper form without permission of ASHRAE. For more information about ASHRAE Journal, visit www.ashrae.org The Hazards of E- Cigarettes BY FRANCIS (BUD) J. OFFERMANN, P.E.. CIH, MEMBER ASHRAE The prevalence of the use of e- cigarettes is increasing. E- cigarettes are marketed as an alternative to smoking tobacco that only produces harmless water vapor, with no adverse impact on indoor air quality. However, published literature seems to show that e- cigarettes are not harmless.l Photo I shows an e- cigarette user exhaling a dense visible aerosol into the surrounding air. This visible aerosol consists of condensed submicron liquid droplets, which contain many chemicals including some that are carcinogenic, such as formaldehyde, metals (cadmium, lead, nickel), and nitrosamines. Figure 1 is a schematic of typical e- cigarette compo- nents. E- cigarettes contain a liquid, typically propylene glycol and /or glycerol, that include varying amounts of nicotine (e.g., 0 to 36 mg /mQ as well as flavorants. A wicking material is used to transport the liquid by capil- lary action from a reservoir to the heater. When the user draws on the e- cigarette, a sensor detects the draw and a microprocessor activates the heater, which vaporizes the fluid to produce a saturated vapor at an elevated tempera- ture (i.e., > 350 °C [662 °F] in the center of the heating unite). Propylene glycol, glycerol, and nicotine are liquids with relatively high boiling points: propylene glycol (188 °C [370 0F]), glycerol (290 °C [554 0F]), and nicotine (247 °C [477 0F]). Consequently, the vaporized fluid immediately condenses upon leav ing the heating element, forming an aerosol of submicron spherical liquid droplets with the visible appearance of smoke or fog. While the word vapor is used to describe what e cigarettes produce, and vaping is a term used to describe the What are the chemical emissions from e- cigarettes? We searched through the published literature for infor- mation on the chemical emissions from e- cigarettes. We then used these chemical emissions to calculate the direct exposure to users and the indirect (passive) expo- sure to non - users, with usage and exposure assump- tions selected to produce worst -case exposure scenarios. E- cigarettes do not produce a vapor (gas), but rather a dense visible aerosol of liquid sub - micron droplets consisting of glycols, nicotine, and other chemicals, some of which are carcinogenic (e.g., formaldehyde, metals, nitrosamines). process of inhaling from an e- cigarette. the emissions out of the mouthpiece are not actually a vapor, which is a gas, but rather they are primarily an aerosol. This aerosol consists of submicron particles of the condensed vapor of glycols containing the nicotine and flavorants. So users are not vaping, but rather they are aerosolizing. 38 ASHRAE JOURNAL ashrae.org JUNE 2014 For both the direct and indirect expo- sures, we calculated the hazard quotients as the ratio of the calculated exposures to both cancer and non - cancer health exposure guidelines. Hazard quotients in excess of 1.0 indicate a health risk. The paper by Goniewicz et. al.3 con- tained the largest study of chemical emissions from e- cigarettes and forms the primary basis for our analyses. In this paper the chemical emissions of 11 Chem icals, including carbonyl compounds, volatile organic compounds, tobacco specific nitrosamines, and heavy metals were measured from 12 different e -ciga- rettes. Each e - cigarette was tested three times. A total of 150 puffs (70 mUpuff) were directly vaporized into the analyti cal samplers from an e- cigarette attached to a mechani- cal smoking machine. For our exposure analyses we included seven of the 11 chemicals studied by Goniewicz Francis (Bud) J Offermann, P.E.. CIH, is president of Indoor Environmental Engineering in San Francisco et.al.,3 that had both significant emission rates and rel- evant health -based exposure guidelines. Schripp et. al.z measured the emission rates of propylene glycol from three e- cigarettes. Table I summarizes the minimum and maximum chemi- cal emissions rates for nine chemicals in terms of mass (ug) of chemical per 150 puffs (70 mL/puff). The dominant chemical emitted was propylene glycol, with a range of 250,950 to 828,750 pg /150 puffs. The chemical with the next highest emission rate was nicotine, for which we assumed a concentration of 24 mg /mL of nicotine in pro pylene glycol, yielding 5,770 to 19,060 pg /150 puffs.. Are the chemical emissions from e- cigarettes a health risk? We used the maximum chemical emis- sions in Table 1 to calculate the direct exposure to users and the indirect (passive) exposure to non - users, with the following usage and exposure assumptions, which were selected to produce worst -case exposure scenarios. Direct Exposure Assessment. The median puffs /day by e- cigarette users was assumed to be 1.75 puffs /day with a puff volume of 70 mUpuff. The respiratory absorption of the inhaled vapor was assumed to be 100% for all com- pounds. We assumed a zero exposure other than the vapor that was directly inhaled (i.e., no indirect exposure). Indirect (Passive) Exposure Assessment. We modeled exposures for a small office space (i.e., 20.9 mz [225 ft], 2.4 m [7.9 ft] ceiling), with a low outdoor air ventilation rate of 0.3 h- 1 (assuming openable windows closed and no mechanical ventilation, ABLE 2 Hazard quo! so there is only outdoor air infiltra tion) and no contaminant removal other than ventilation. We assumed CHEMICAL continuous occupancy for eight hours by two occupants: one e cigarette user ACETALDEHYDE (125 puffs in 8 hours. 70 mVpuff) and ACROLEIN one non -user. For this assessment FORMALDEHYDE we assumed that 100% of the inhaled CAOM III M vapor by the user was exhaled into the LEAD indoor air and the respiratory absorp NICKEL tion by occupants of the exhaled NICOTINE vapor in the indoor air was 100% for all compounds. We assumed a zero RNK° exposure when away from work. PROPYLENE GLYCOL COLUMN IAQ APPLICATIONS LED Lights Up When the User M cropiocessor Heater: Vaporizes E- Cigarette Drum on the E- Cigarette Controls Heater and LED Fluid from Heated Wick (pG /150 PUFFS - 70 NILIPUFF) INDIRECT Battery I Minimum VF .4 2.0 .. W Sensor Detects ACROIEIN When User Dravis Mouthpiece (Condenser). Vapors 41.9 Condense into an Aerosol of Liquid 3,2 Sub - Micron Droplets of E- Cigarette Fluid Schematic of the typical components found in an e- cigarette. 9NNK 4-( n- nitrosomethylam ino)- 1- (3- pyridyl)l- butanone EXPOSURE CRITERIA CHEMICAL EMISSIONS INDIRECT EXPOSURE CHEMICAL (pG /150 PUFFS - 70 NILIPUFF) INDIRECT EXPOSURE HQ a Minimum Maximum ACETALOEHYDE 2.0 13.6 ACROIEIN <0.02 41.9 FORMALDEHYDE 3,2 56.1 CADMIUM <0.04 0.22 LEAD 0.03 0.57 NICKEL 0,11 0.29 NICOTINE 5,770 19,060 N N K' <0.0001 0.028 PROPYLENE GLYCOL 250,950 828,750 9NNK 4-( n- nitrosomethylam ino)- 1- (3- pyridyl)l- butanone EXPOSURE CRITERIA DIRECT EXPOSURE INDIRECT EXPOSURE NSRL CREL HQ ° HQ a HQ ° HQ ' (pg /day) NSRL CREL NSRL CREL_ 90 140 018 0.01 0.004 0.0001 N/A 0.35 N/A 7.0 N/A 0.17 40 9 1.64 0.36 0.04 0.009 0.05 0.02 5.13 0.64 0.12 0.015 0.5 0.15 1.33 0.22 0.03 0.005 0.8 0.05 0.42 0.34 0.008 0.007 N/A 5 N/A 222 N/A 5.4 0.014 N/A 2.36 N/A 0.05 PI /A N/A 50 N/A 967 N/A 23 For cancer health effects we used the Haza(G quotlent5 eel Lsard a I e Gro 0 expos!ue to he 01, anti t,RFt. health exposure guitlehnef; California Office of Environmental above 1 J bolded Health Hazard Assessment, I No �)J4 4 i (,3 ,yndy0l dutanone JUNE 2014 ashrae.org ASHRAE JOURNAL 39 a COLUMN IAQ APPLICAiMIS Significant Risk Levels (NSRLs). The NSRL is the 70 year related health effects, four of the nine chemicals ana- average daily intake level calculated to result in one excess lyzed exceeded 1.0 for the direct exposure to users; lead case of cancer in an exposed population of 100,000. For (1.33), formaldehyde (1.64), NNK (2.36), and cadmium non- cancer health effects, we used the California Office of Environmental Health Hazard Assessments Chronic Reference Exposure Guidelines (CRF,Ls). For propylene glycol and nicotine, which do not have established CRELs, we used 1% of the California OSHA6 occupational eight -hour Permissible Exposure Guideline, and for lead we used the Environmental ProtectionAgency7 National Ambient Air Quality Standards (NAAQS), three -month average requirement For both the direct and indirect exposures, we calcu- lated the hazard quotients as the ratio of the calculated exposures to the cancer (NSRL) and non - cancer (CREL) health exposure guidelines. Hazard quotients in excess of 1.0 indicate a health risk. Table 2 summarizes the hazard quotients associated with the direct exposures of e- cigarette users and the indirect (passive) exposures of non - users. With respect to the NSRL hazard quotients for cancer 42 ASNRAE JOURNAL ashrae,org JUNE 2014 (5.13). For the indirect exposure to non - users, the NSRL hazard quotients were all less than 1.0, with the high- est, cadmium (0.12). With respect to the CREL hazard quotients for non - cancer related health effects, three of the nine chemicals analyzed exceeded 1.0 for the direct exposure to users: acrolein (7.0), nicotine (222), and propylene glycol (967). For the indirect exposure to non- users, the CREL hazard quotients also exceeded 1.0 for nicotine (5.4) and propylene glycol (23). If we use the minimum rather than the maximum chemical emissions in Table 1, the modeled direct and indirect CREL hazard quotients still exceed 1.0 for pro- pylene glycol (293 direct and 7.0 indirect) and nicotine (65 direct and 1.6 indirect). With respect to the modeled indirect exposures, we note that while this was a worst -case exposure scenario with a low ventilation rate of 0.3 h -1, even if ventilation rates are tripled to 0.9 h -1, which exceeds ASHRAE Standard 62.18 default minimum ventilation of 0.78 h -1 for the mod- eled office space, the indirect exposures still present a significant health risk. Ventilation rates would have to be increased by a factor of 23 to mitigate the health risks for each of the nine chemicals modeled. Clearly, ventilation is not a solution and e- cigarette use will have to be regulated indoors in the same manner as is done for tobacco smok- ing. which is prohibited indoors. We also note that there has been little research into the emissions of the flavorants that are added into the e -cig- arette fluids. Some flavorant chemicals. such as diacetal, while having no apparent adverse effects when ingested, when aerosolized and inhaled can cause lung irritation. Like the flavorants, the propylene glycol carrier. while used as a preservative in food products with - out apparent adverse health effects, are themselves a potential airborne respiratory irritant. Wieslander et. al. `' conducted experimental studies of 27 individu als exposed to propylene glycol aerosol for a one minute period with airborne concentrations ranging from 176 to 851 mg /m3 (geometric mean of 309 mg /ms). Results of post - exposure measurements of tear film sta- bility and forced expiratory respiratory volume indicated that short -term exposures to propylene glycol aerosol can cause acute eye and upper respiratory irritation in non - asthmatic patients. COLUMN IN APPLICATIONS Conclusions We conclude that e- cigarettes emit harmful chemi- cals into the air and need to be regulated in the same manner as tobacco smoking. There is evidence that nitrosamines, a group of carcinogens found specifically in tobacco, are carried over into the e- cigarette fluid from the nicotine extraction process.10 There is also evidence that the glycol carriers can by oxidized by the heating elements used in e- cigarettes to vaporize the liquids, creating aldehydes such as formaldehyde. II Consumers should be warned that, while the health risks associated with the usage of e- cigarettes are less than those associated with tobacco smoking, there remain substantial health risks associated with the use of e- cigarettes. References 1. Offermann, F. 2014. "Chemical Emissions from E- Cigarettes: Direct and Indirect Passive Exposures." Indoor air 2014 Conference Proceedings. 2. Schripp, T., et al. 2013. "Does e- cigarette consumption cause passive vaping ?" IndoorAir23(1):25 -31. 3. Goniewicz, M., K. Knysak, M. Gawron. 2013. "Levels of selected carcinogens and toxicants in vapor from electronic cigarettes:' Tobacco Control, March. 4. Office of Environmental Health Hazard Assessment. 2013. "Proposition 65 Safe Harbor Levels. No Significant Risk Levels for Carcinogens and Maximum Allowable Dose Levels for Chemicals Causing Reproductive Toxicity." Nvww.oehha.ca.gov /prop65 /pdf/ safeharbor081513.pdf. 5. Office of Environmental Health Hazard Assessment. 2014. "All OEHHAAcute, 8-hour and Chronic Reference Exposure Levels." ww-Vv. oehha.ca.gov/air/allrels.htmi. 6. California OSHA. 2013. TableAC -1, Permissible Exposure Limits for Chemical Contaminants. www.dir.ca.gov /title8 /ael.pdf. 7. Environmental Protection Agency. 2013. National Air Quality Standards (NAAQS). www.epa.gov /air /criteria.html. 8. ASHRAE Standard 62.1-2013, VentilationforAcceptablelndoorAirQuolity. 9. Wieslander G, et al. 2011. "Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respi- ratory effects:' Occupational and Environmental Medicine, 58(10): 649 -655. 10. Kim. H., H. Shin. 2013. "Determination of tobacco- specific nitro - samines in replacement liquids of electronic cigarettes by liquid chro- matography- tandem mass spectrometry." Journal of Chromatography A. 11.Ohta. K., et al. 2011. "Determination of carbonyl compounds generated from the electronic cigarette using coupled silica cartridges impregnated with hydroquinone and 24- dinitropherry1hydrazine." Bunseki Kagaku; 60:791 -797. ■ Advertisement fbrmed y in this space. 44 AS!iRAE JOURNAL ashrae.org JUNE 2014 JUNE 2014 ashrae.org ASNRAE JOURNAL I 0 9 E- cigarettes (a product category that includes disposable cigarette -like, e- hookah, vape pens, and refillable tank -like or personal vaporizers) are devices that heat a solution (nicotine and other additives) producing a vapor that is inhaled without combustion. E- cigarettes vary in quality, safety, size, and efficiency of nicotine delivery. Current scientific evidence indicates that e- cigarettes are likely less harmful to individual users than combustible cigarettes. Since they have been on the market for under 10 years, their long -term effects are unclear. The science regarding how these evolving products impact patterns of tobacco use and public health is still in the early stages, but growing. This fact sheet contains information about e- cigarettes as it is known as of the date at the bottom of the page, and will be updated regularly as the science base grows. SUMMARY OF LEGACY'S POSITION ON E- CIGARETTES Policies and regulation of e- cigarettes must ensure they are as safe as possible and that individual and population benefits are maximized while harms are minimized especially to youth. One of the conclusions of the 2014 Surgeon General's Report on The Health Consequences of Smoking stated, "the burden of death and disease from tobacco in the United States is overwhelmingly caused by cigarettes and other combusted tobacco products; rapid elimination of their use will dramatically reduce this burden "'. Thus, prudently regulated, e- cigarettes hold promise as one means to move smokers to a less harmful product and reduce the devastating death and disease burden caused by combustible tobacco products such as cigarettes, cigars, or hookah.' Legacy's vision is a generation that rejects tobacco. Our primary goal is to achieve a society that rejects tobacco For those already using combustible tobacco and are unable or unwilling to stop, we support movement to the exclusive use of less harmful alternatives with the goal of eventually stopping all tobacco use Legacy supports the following recommendations with regard to e- cigarettes: Prudent and expeditious regulation of e- cigarettes to maximize benefits and minimize harms to protect individuals and public health, especially youth Restriction and enforcement of e- cigarette sales and marketing so that it does not: • Target or appeal to youth • Mislead the public Encourage dual use Undermine smoke -free air laws Restricting sales of e- cigarettes to those 18 and older • Elimination of candy flavorings that especially appeal to youth • Inclusion of e- cigarettes in smoke -free indoor air laws • Providing manufacturing and safety standards, including child -proof packaging of e- liquids and cartridges, accurate labeling of ingredients and nicotine levels, etc. 'Z•a MASS 'r,:HUSFTT6 1V N4N' I VdA.SNIIJ , i :,iJ IX 100; , i T . :: , iI: l.5 55 F 27 %.45/_: ;S�)9 ! LEGACY FORHEALTH.ORG Revised .. �7�1�Irtir��etrr�L�►� o Typically e- cigarettes have three integrated components s -': 1, a cartridge or reservoir containing solution, 2, a breath or user - activated battery - powered heating element (atomizer) which vaporizes the solution, and 3. a battery (at varying sizes and capacities) o When activated, the heating element produces a vapor from a solution containing the humectant carrier (e.g., propylene glycol, glycerine), nicotine, flavorings, and other ingredients. 3,6,8-12 LEGAL STATUS AND REGULATION Currently, there is little to no government oversight of e- cigarettes - either with regard to manufacturing and product standards, or their advertising and marketing. In April 2014, FDA proposed a rule that would deem e- cigarettes as tobacco products and allow FDA to regulate them 13 That proposal has not yet been finalized, and e- cigarettes remain unregulated at the federal level. In the absence of federal regulation, states and localities have pursued legislation regarding e- cigarettes: • As of May 2014, 34 states have prohibited the sale of e- cigarettes to minors .14 • As of April 29, 2014, three states (North Dakota, New Jersey, and Utah) and 172 local governments have included e- cigarettes in their indoor air laws and smoking bans.' • The U.S. Department of Transportation has proposed a ban on the use of e- cigarettes on planes, but that rule has not been finalized.' Several airlines have prohibited smoking e- cigarettes on their aircraft on their own accord",lP MARKETING • Widespread marketing of e- cigarettes and the entry of the three big U.S. tobacco companies into the e- cigarette market have contributed to increased attention to these products. Sales of e- cigarettes approached $2 billion in 2013, and are estimated to surpass $10 billion by 2017.19 • Unlike traditional tobacco products such as cigarettes and smokeless tobacco, e- cigarettes and associated components (solution, atomizers) are currently not subject to regulations in terms of where (e.g., broadcast, print) and to whom (e.g., minors) they are marketed. • E- cigarettes have been endorsed by several celebrities and have appeared on cable television, in a variety of print and web media, and at sponsorships of events .20-22 These marketing strategies are of concern because of their potential to reach youth audiences .1324 • Some e- cigarette companies have advertised their products using health - related claims. E- cigarettes have also been marketed as a way to circumvent smoking bans and indoor air restriction s. 25 -28 • Lorillard Tobacco Company, owner of blu e- cigarettes, has made by far the largest advertising expenditures to date .29 Lorillard and others have advertised in channels where youth have high exposure levels to those ads. '4 Further, some companies use marketing messages reminiscent of historic cigarette marketing or that encourages dual use of tobacco products rather than complete switching to e- cigarettes30 (D.M. Vallone, unpublished data, February 2014). However, this is not necessarily the case for all e- cigarette companies. -1 M,a_5:' FIUSF "tT q -"\VF, NA ' VV aSIa Ni,InN D' 200,,F, T . :..d5<i ti 5 F LJ _f 4.`. ;9a LEGACY FOR HEALTH.ORG Rov. =. G ^; v 20'4 2/8 CONSUMER PERCEPTIONS Awareness Overall awareness of e- cigarettes is growing among U.S, adults aged 18 and older, doubling from 16.4% in 2009 to 32.2% in 201031 and increasing again to 7S.4% in 2012.32 Awareness is highest among current smokers and young adu lts,32 -34 Harm Perceptions & Reasons for Use • E- cigarettes are generally perceived to be less harmful than regular cigarettes by e- cigarette users .35 • The most commonly cited reasons for use include perceptions that e- cigarettes: • are less harmful /less toxic than regular cigarettes, 32,36-38 • are less expensive than regular cigarette S,32,39 • help reduce tobacco craving /withdrawal symptoms,37 • reduce amount smoked and use as a reduction /cessation aid,32,36,.38.40AI and • prevent relapse to regular cigarettes. 35,37 o Other reasons for use include ability to avoid smoking restrictions in public venues, and that e- cigarettes are less likely to bother nonsmokers via secondhand exposure .35 PATTERNS OF USE Adults • Ever use of e- cigarettes is highest among current cigarette smoking adults in the U.S. and increased from 9.8% in 2010 to 21.2% in 2011 to 32% in 2012 32.33 • About 8.1% of adults have ever tried e- cigarettes, with higher rates in young adults (9.3% among 18 -24 year olds) and those with less education (8.6% s12 years education). This study also showed that 18% of those who have ever used e- cigarettes continue as current users .32 Youth Ever use of e- cigarettes more than doubled from 3.3% in 2011 to 6.8% in 2012 among U.S. middle and high school students .41 The majority of youth e- cigarette users are current smokers, and data from 2012 showed that 80.5 % of high school students who were past 30 -day e- cigarette users were also past 30 -day regular cigarette smokers .42 Dual use of e- cigarettes and regular cigarettes increased from 0.8% to 1.6% among middle school students from 2011 -2012 and from 0.8% to 1.9% among high school students from 2010 - 2011.12,13 Current data is insufficient to determine whether e- cigarettes are a gateway to cigarette use, a gateway out of cigarette use or have no influence on cigarette use. More data is needed in this area. Youth who have tried e- cigarettes also indicate greater motivation to quit smoking, suggesting they may want to stop using combustible cigarettes .41 CIGARETTE SMOKING CESSATION /REDUCTION • Two randomized controlled trials to date showed that e- cigarettes were effective in helping adult smokers to quit or to reduce their cigarette consumption."" In one of these studies, rates of smoking cessation in the e- cigarette study group were similar to those reported in the nicotine patch group and also to those seen in previous clinical trials of nicotine replacement therapy.1541 • Several observational studies suggest that e- cigarettes can help adult smokers quit smoking WAWW I7724 MASS:,-\CHUS-F US AVE, NW I WASHIN61 ON, 1?,7 20036) 1 T 20-1454.55155 F 20',41'34 559 9 LEGACY FORHEALTH.ORG Revi;;vd' ^ t 20;4 3/8 combustible cigarettes or reduce the number smoked .1.36.111-1,1 Other studies report use of e- cigarettes may be associated with no change or less cessation, but these associations may be due to other factors (e.g. smokers who are more nicotine dependent are more likely to try e- cigarettes). I0,5S,56 More research is needed to further determine whether and how e- cigarettes can be an effective cigarette cessation or harm reduction aid. HEALTH & SAFETY Nicotine Nicotine is derived from tobacco and has psychoactive and physiological effects. Nicotine can be harmful to those with cardiovascular diseases and diabetes or other chronic medical illnesses. Nicotine is a potent poison when mishandled, ingested or absorbed through the skin. It is known to cause birth defects during pregnancy and affects the developing brain so should not be used by youth. Nicotine is an addictive substance, but its level of addictiveness can vary depending on its mode of delivery. For example, in cigarettes, nicotine is highly addictive. On the other hand, FDA - approved NRTs are minimally addictive and can be used long term. Studies suggest that the current generation of e- cigarettes on the market are less addictive than combustible cigarettes and closer in profile to N RTs.9,S7 User experience and e- cigarette product selection may influence nicotine delivery from e- cigarettes. Several studies indicate that e- cigarettes, under certain conditions, can deliver nicotine reliably and effectively... 8-64 Some e- cigarette brands may yield little or minimal nicotine delivery due to design and /or mislabeling of the nicotine amount. 3,8,10,65 Some e- cigarette solutions and vapors contain nicotine doses that are not consistent with manufacturer specifications.9 Vapor • Health effects associated with exposure to e- cigarette vapor are not fully studied, but available data suggest that e- cigarette vapor is less harmful than cigarette smoke .611-72 However, e- cigarette vapor is not water vapor. • E- cigarettes vary in quality and vapor constituents. • In contrast to combustible products, existing studies of e- cigarettes report that e- cigarette vapor produces no carbon monoxide and fewer chemicals.,' 1`1-11 The chemicals that are present are at lower levels of toxicity than in smoke from combustible tobacco products like cigarettes, cigars, pipes, or hookah. • Potentially harmful constituents have been identified (typically 1 -3 orders of magnitude lower than in cigarettes) in some e- cigarette liquid and vapor, including nitrosamines, heavy metals, and carbonyl S. 57.64.1 5,66,69,72,74,7T E- cigarettes contain propylene glycol, which has not been studied for long -term safety via inhalation .y� 6465 Mainstream vapor from e- cigarettes contains measurable levels of nicotine. Some studies also show that e- cigarette vapor when exhaled by the user emits low levels of nicotine and particulate matter into the air. F1.11.11,72 There is concern with exposing bystanders, including youth and pregnant women, to nicotine in the air, even at low levels.69 Adverse Events o Studies demonstrate e- cigarettes do not produce the same acute adverse health effects observed with conventional cigarette smoking (e.g. eye, nose, and throat irritation, coughing and bronchitis, 1 -2.1 MASS ACHUSETTS AVF, NW 1 WASHINGTON, N7 20036 1 T 20'.,454,5555 F 202.454. 5599 1 LEGACY FORHEALTH.ORG R'vi, -eci' ^lai 0;'4 4/8 inflammation of tissues in the mouth, nose, and throat, bronchitis, increased heart rate and blood pressure) 16 • Common adverse effects associated with e- cigarette use include minor complaints or irritation relating to the mouth, eyes, and upper respiratory system.'' • Nicotine is a potent poison and can cause death if not properly stored and handled. Small ingestions could be deadly. With an estimated median lethal dose between 1 and 13 mg per kilogram of body weight, 1 teaspoon (5 ml) of a 1.8% nicotine solution could be lethal to a 90 -kg person.'° • The number of calls to poison centers involving e- cigarette liquids containing nicotine rose from one per month in September 2010 to 215 per month in February 2014. More than half of these calls involved young children S years old and under.i5 A serious poisoning of a 10 month old infant occurred.30 • Poisoning related to the nicotine in e- cigarette liquid can occur by ingestion, inhalation, or absorption through the skin or eyes. The most common adverse health effects mentioned in e- cigarette calls were vomiting, nausea, and eye irritation." REFERENCES U.S. Department of Health and Human Services. The Health Consequences of Smoking -50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Departfrrent of Health and Human Services. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections. January 2011. Page 19 of Executive Summary. Abrams DB. Promise and peril of e- cigarettes: can disruptive technology make cigarettes obsolete? LAMA : the /Ournal of the American Medical Association. Jan S 2014;311(2):135 -136, Williams M, Talbot P. Variability among electronic cigarettes in the pressure drop, airflow rate. and aerosol production. Nicotine & tobacco research : official iourna/ of the Society for Research on Nicotine and Tobacco. Dec 2011:13(12):1276 -1283. Foulds J, Veldheer S, Berg A. Electronic cigarettes (e- cigs): views of aficionados and clinical /public health perspectives. International journal of clinical practice. Oct 2011;65(10):1037 -1042. Dawkins L. Turner J, Roberts A, Soar K. 'Vaping' profiles and preferences an online survey of electronic cigarette users. Addiction, (Abingdon, England,). Jun 2013:108(6):1115 -1125. Cobb NK. Bvron MJ, .Abrams DB, Shields PG. Novel nicotine delivery systems and public health: the rise of the "e- cigarette ". American Journal of public health. Dec 2010;100(12):2340 - 2312. Trtchounian A. Talbot P. Electronic nicotine delivery systems: is there a need for regulation? Tobacco control. Jan 2011;20(1):47 -52. Trtchounian A, Williams M, Talbot P. Conventional and electronic cigarettes (e- cigarettes) have different smoking characteristics. Nicotine & tobacco research.- official iournal of the Society for Research on Nicotine and Tobacco. Sep 200;12(9):905 -912. Goniewicz ML, Kuma T, Gawron M. Knysak J, Kosmider L. Nicotine levels in electronic cigarettes. Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco. Jan 2'013;15(1):158 -166. C.anleron JM. Howell DN. White JR. Andrenyak DM, Layton ME, Roll JM. Variable and potentially fatal amounts of nicotine in c:- cigarette nicotine solutions. Tobacco control. Feb IS 2013. Kubica P, Kot -Wasik A, Wasik A, Namiesnik J. "Dilute & shoot" approach for rapid determination of trace amounts of nicotine in zero -level e- liquids by reversed phase liquid chromatography and hydrophilic interactions liquid chromatographv coupled with tandem mass spectrometry- electrospray ionization. Journal ofchrornatography. A. May 10 2013;1289:13 -18. Etter JF. Zather E, Svensson S. Analysis of refill liquids for electronic cigarettes. Addiction (Abingdon. England). Sep 2013:108(9):1671 -1679. 'S Federal Register. Deernina Tobacco Products To Be Subject to the Federal Food, Drug, and Cosr?retic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. A Proposed Rule by the Food and Drug Administration. April 25, 2014. hops !Feder l,rzgisterg.oy /,x',2_014 - 09491. National Conference of State Legislatures. Alternative Nicotine Products /Electronic Cigarettes. http ;;rwyrvv_n_sLorgLes2rchr health,'alternztiye ntcgtina- f>redu _ts e curettes asps:. Accessed May 5, 2014. American Nonsmokers' Rights Foundation. U.S. State and Local Laws Regulating Use of Electronic Cigarettes. http: vywvvrlg- mol a .gig /1.20 Cigs.1a.ws.pdf. Accessed May 13, 2014. 1724 MASSACHUSETTS AVE, NW I WASHINGTON. DC 20036 I T 202.454.5555 F 202454.5599 l LEGACY FORHEALTH.ORG Revised flay 2074 5/8 16 Smoking of Electronic Cigarettes on Aircraft, Final Rule, 76 Fed. Reg. 57008 -57012 (September 15, 2011) (to be codified at 14 c.f.R. pt. 252). "JetBlue. Electronic., /Smokeless Cigarettes. http:; ;:helpietbk4e.ggm!5R4'S Sit G1= 61_N,!we.blsapi,c[Vj ?St =2f!5, E =0000000000113 -;490 29.K_9756 5xi, 1.Caszobi%1-8395995 %029. Accessed July 2, 2013, American Airlines. Keeping Passengers and Employees Safe at All Times. 2008; htt .p ; ;1w_ww.aa.com.•'.il8njamrc� rp__ co �oratelntormation _factsisafetsp. Accessed July 2, 2013. ' Herzog B. Gerberi J. Equity Research: E -Gigs Revolutionizing the Tobacco industry. Wells Fargo Securities, LLC Equity Research DepartiTient2013. ]-'Kress M. Big Three Moving Ouickiv in Growing E- Cigarette Presence. Convenience Store News. 2013. h_tt_p:/".'wA_w­..c s-new-s.com/lop stork- tobacco= c4_big three moyincg_quickl_y in urow_i_nr�e_c arette presencz 0469 .h.tml. Kamerow D. Big Tobacco lights up e- cigarettes. B1,1J (Clinical research ed.). 2013:346:f3418. 72Can)paign for Tobacco -Free Kids. 7 Ways E- Cigarette Companies are Copying Big Tobacco's Playbook (or 7 reasons FDA should quickly regulate e- cigarettes). 2013: http;% wrvrfitobaccofreekids. org, ,'tobacco_unfilteredlpost,'2013 10_02- ecigarettes. Accessed November 8, 2013. 'Staff of Senators Durbin, Harkin, Rockefeller. Blumenthal, Markey, Brown, Reed. Boxer, Merkley and Representatives Waxman and Pallone. Gatewa�v to Addiction? A Survey of Popular Electronic Cigarette Manufacturers and Targeted Marketing to Youth. April 14, 2014. Legacy. Vaporized: E- Cigarettes. Advertising, and Youth. 2014. =4blu eCigs. blu cartridges. 2013: httf ;_ %www Iticjgs.com1store�c�ir_tnclges. Accessed July 2, 2013. Food and Drug Administration. Transcript for FDA's Media Briefing on Electronic Cigarettes. Moderator: Judy Leon. July 22,2009.1:30 pm CT. 2009. = 'Grana RA, Ling PM. "Smoking revolution ": a content analysis of electronic cigarette retail webs tes. Arnericarr jounnal of preventive medicine. Apr 2014;46(4):395 -403. ' NJOY. NJOY. 2013; htt,p ._w..w_,w_n1ov�,co,my'. Accessed July 3, 2013. Spielman A, Azer V. Disruptive innovation: ten things to stop and think about (e- cigarettes). Citi GPS: Global Perspectives & SOILItions. 2013 Apr. 19 -22. OCampaign for Tobacco -Free Kids. 7 Ways E- Cigarette Companies Are Copying Big Tobacco's Playbook 2013; I ;lt1p /www, tobaccofreelcids_orci,L/ oL?acc:p_ 14nfiltered!?ostl2C�13 iC1_O_2_eciaarettes. Accessed May 13, 2014. `° Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems adult use and awareness of the 'e- cigarette' in the USA. Tobacco control. Jan 2013;22(1):19 -23. Zhu SH, Gamst A, Lee M, Cu nmins S, Yin L, Zoref L. The Use and Perception of Electronic Cigarettes and SnuS among the U.S. Population. PloS one. 2013:8(10):e79332. 33 King BA, Alam S, Promoff G. Arrazola R, Dube SR. Awareness and ever -use of electronic cigarettes among u.s. Adults, 2010 -2011, Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco. Sep 2013:15(9):1623 -1627. Pearson JL, Richardson A. Niaura RS, Vallone DM, Abrams DB. e- Cigarette awareness, use. and harm perceptions in US adults. American journal of public health. Sep 2012;102('9):1758 -1766, Etter JF. Electronic: cigarettes: a survey of users. BMC public health. 2.010;10:231. ",Goniewicz ML, Lingas EO, Hajek P. Patterns of electronic: cigarette use and user beliefs about their safety and benefits: an Internet Survey. Drug and alcohol review. Mar 2013;32(2):133 -140. 3` Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction (Abingdon. England). Nov 2011;106(11):2017 -2028, Li J, Bu11en C. Newcornbe R, Walker N, Walton D. The use and acceptability of electronic cigarettes among New Zealand smokers. The New Zealand medical journal. 2013;126(1375):48 -5 7. 1'McQueen A. Tower S, Sumner W. Interviews with "vapors ": implications for future research with electronic cigarettes. Nicotine & tobacco research: official journal Of the Society for Research on Nicotine and Tobacco. Sep 2011;13(9):860 -867. "'vickerman KA, Carpenter KM, Altman T. Nash CM, Zbikowski SM. Use of Electronic Cigarettes Among State Tobacco Cessation Quitline Callers. Nicotine & tobacco research, . official iournal of the Society for Research On Nicotine and Tobacco, May 8 2013. Kralikova E, Novak J, West O, Kmetova A, Hajek P. Do e- cigarettes have the potential to compete with conventional cigarettes? A survey of conventional cigarette Smokers' experiences with e- cigarettes, Chest. JUI 18 2013. "Centers for Disease Control and Prevention. Notes from the field: electronic cigarette use among middle and high School students - United States, 2011-2012. rtiIMWR. Morbidity and mortality weekly report. Sep 6 2013;6'_(35):729 -730. Camenga DR, Delmerico J, Kong G, et al. Trends in use of electronic nicotine delivery systems by adolescents. Addictive behaviors. Sep 17 2011 "Dutra L.M, Glantz SA. Electronic. Cigarettes and Conventional Cigarette Use Among US Adolescents: A Cross- sectional Study. JAMA Pediatrics. Mar 6 2014, °`Bullen C. Howe C. Laugesen M, et al. Electronic cigarettes for sn)oking cessation: a randornised controlled trial. Lancet. Sep 9"_'013. 1721 MASSACHUSETTS AVE, NW I WASHINGTON. DC 20036 1 T 202.454.5555 F 202.454.5599 i LEGACY FORHEALTH.ORG Revised hiay 20:4 6/8 "'Caponnetto P, Campagna D. Cibella F, et al. EffiCiency and Safety of an eLectronic. cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12 -month randomized control design study. PloS one. 2013;8(6):e66317. Fiore M, United States. Tobacco Use and Dependence Guideline Panel. Treating tobacco use and dependence: 2008 update. 2008 update ed. Rockville, Md.: U.S. Dept. of Health and Human Services: Public Health Service: 2008. °` Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R. Impact of an electronic cigarette on smoking reduction and cessation ® in schizophrenic smokers: a prospective 12 -month pilot study. international journal of environmental research and public health. Feb 2013;10(2):446 -461. '" Caponnetto P, Polosa R, Russo C, Leotta C. Campagna D. Successful smoking cessation with electronic cigarettes in smokers with a documented history of recurring relapses: a case series. Journal of medical ease reports. 2011;5(1):585. °Polosa R. Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e- Cigarette) on smoking reduction and cessation: a prospective 6 -month pilot study. 8MC public health. 2011;11:786. " Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking- cessation: tool results from an online survey. American journal of preventive medicine. Apr 2011;40(4):472 -475, 52 Etter JF, Bullen C. A longitudinal study of electronic cigarette users. Addictive behaviors. Oct 30 2013. "'Polosa R, Morjaria JB. Caponnetto P, et al. Effectiveness and tolerability of electronic cigarette in real -life: a 24 -month prospective observational study. Internal and emergency medicine. Jul 20 2013. c14Adkison SE, O'Connor RJ, Bansal- Travers M, et al. Electronic nicotine delivery systems: international tobacco control four - country survey. American journal of preventive medicine. Mar 2013;44(3):207 -215. "Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAI-14 internal medicine. May 12014:174(5):812-813. `c Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. American journal of public health. May ^_013;103(5):923 -930. 17Goniewicz ML, Knysak J, Gawron M. et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco control. Mar 6 2013. Etter JF, BUllen C. Saliva cotinine levels in users of electronic. cigarettes. The European respiratory journal. Nov 2011;38(5):1219 -1220. 5'Bullen C, McRobbie H, Thornley S, Glover M, Lin R. Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross -over trial, Tobacco control. Apr 2010;19(2):98 -103. °Vansickel AR, Eissenberg T. Electronic cigarettes: effective nicotine delivery after acute administration. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. Jan 2013;15(1):267 -270. Vansickel AR. Weaver MF, Eissenberg T. Clinical laboratory assessment of the abuse liability of an electronic cigarette. Addiction (Abingdon. England). Aug 2012;107(8):1493 -1500. �"Eissenberg T. Electronic nicotine delivery devices: ineffective nicotine delivery and craving suppression after acute administration. Tobacco control. Feb 2010;19(1):87 -88. r'Vansickel AR, Cobb CO, Weaver MF, Eissenbera TE. A clinical laboratory model for evaluating the acute effects of electronic "cigarettes ": nicotine delivery profile and cardiovascular and subjective effects. Cancer epidemiology, biomarkers & prevention a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. Aug 2010:19(8):1945-1953. ^Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e- cigarettes) impairs indoor air quality and increases FeNO levels of e- cigarette consumers. International journal of hygiene and environmental health. Dec 6 2013. ^`Cheah NP. Chong NW. Tan J, Morsed FA, Yee SK. Electronic nicotine delivery systerns: regulatory and safety challenges. Singapore perspective. Tobacco control. Dec 1 2012. ee Hadwiger ME, Trehy ML, Ye W, Moore T. Allaire J, Westenberger B. Identification of amino- tacialafil and rimonabant in electronic cigarette products using high pressure liquid chromatography with diode array and tandem mass spectrometric. detection. J Chrornatogr A. Nov 26 2010;1217(48):75 47 -7555. " Westenberger B. Evaluation of e- cigarettes. St Louis, MO: Food and Drug Administration, 2009:1 -8. "McAuley TIN, Hopl.e PK, Zhao J. Babaian S. Comparison of the effects of e- cigarette vapor and cigarette smoke on indoor air quality. Inhalation toxicology. Oct 2012:24(12):850-857. �"Czogala J, Goniewicz ML, Fidelus B. Zielinska -Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. Jun 014:16(6):655 -662. "Pellegrino RM, Tinghino B, Mangiaracina G, et al. Electronic cigarettes: an evaluation of exposure to chemicals and fine particulate matter (PM). Annali di igiene : medicina preventrva e di comunita. Jul -Aug 2012;24(4):279 -288. " Ruprecht AA, De Marco C. Pozzi P. et al. Comparison between particulate matter and ultrafine particle emission by electronic and normal cigarettes in real -life conditions. Tumori. Jan -Feb 2014;100(1):e24 -27. is"Schripp T, Markewitz D, Uhde E, Salthammer T. Does e- cigarette consumption cause passive vaping? Indoor air. Feb 2013;25(1):25 -31. 1724 MASSACHUSETTS AVF, NW I WASHINGTON. DC 20036 1 T 201454.5555 F 202.454.5589 I LEGACYFORHEALTH.ORG Revised Alay 2014 7/8 • S Flouris AD, Chorti MS. Poulianiti KP. et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and kung function, Inhalation tomco logy. Feb 2013;25(2):91 -101. " Williams M. Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PioS one. 2013;8(3):e57987. ' Kim HJ, Shin HS. Determination of tobacco- specific nitrosarnines in replacernent liquids of electronic cigarettes by liquid chromatography- tandem mass spectrometry. Journal of chromatographyy. A. May 24 2013:1291:48 -55. Dawkins L. Corcoran 0. Acute electronic cigarette use: nicotine delivery and subjective effects in regular users. Psychopharmacology. Aug 27 2013. "Chen IL. FDA summary of adverse events on electronic cigarettes. Nicotine & tobacco research : Official journal of the Society for Research on Nicotine and Tobacco. Feb 2013;15(2):615 -616. 'Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self - experiments in the nineteenth century. Archives of tovicolog_V. Jan 2014;88(1):5 -7. "' Chatham- Stephens K, Law R, Taylor E, et al. Notes from the field: calls to poison centers for exposures to electronic cigarettes- - United States, September 2010- February 2014, MP(WR. Morbidity and roortaNty K,eekly report. Apr 4 _'_014:63(13):292 -293. Bassett RA, Osterhoudt K, Brabazon T. Nicotine Poisoning in an Infant. The New England journal ofinedicine. May 7 2014. 1724 MASSACHUSETTS AVE, NW I WASHINGTON. DC 20036 1 T 20_'..454.5555 F 202.454.5599 1 LEGACY FORHEALTH.ORG Revised'Clay20 4 8/8 I ]k AMERICANS FOR NONSMOKERS' RIGHTS Defending your right to breathe smokefree air since 1976 Electronic (e -) Cigarettes and Secondhand Aerosol "If you are around somebody who is using e- cigarettes, you are breathing an aerosol of exhaled nicotine, ultra -fine particles, volatile organic compounds, and other toxins," Dr. Stanton Glantz, Director for the Center for Tobacco Control Research and Education at the University of California, San Francisco. Current Legislative Landscape • As of January 2, 2014, 108 municipalities and three states include e- cigarettes as products that are prohibited from use in smokefree environments. Constituents of Secondhand Aerosol E- cigarettes do not just emit "harmless water vapor." Secondhand e- cigarette aerosol (incorrectly called vapor by the industry) contains nicotine, ultrafine particles and low levels of toxins that are known to cause cancer. • 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.' • Exposure to fine and ultrafine particles may exacerbate respiratory ailments like asthma, and constrict arteries which could trigger a heart attack . 2 • At least 10 chemicals identified in e- cigarette aerosol are on California's Proposition 65 list of carcinogens and reproductive toxins, also known as the Safe Drinking Water and Toxic Enforcement Act of 1986. The compounds that have already been identified in mainstream (MS) or secondhand (SS) e- cigarette aerosol include: Acetaldehyde (MS), Benzene (SS), Cadmium (MS), Formaldehyde (MS,SS), Isoprene (SS), Lead (MS), Nickel (MS), Nicotine (MS, SS), N- Nitrosonornicotine (MS, SS), Toluene (MS, SS).3,4 • E- cigarettes contain and emit propylene glycol, a chemical that is used as a base in e- cigarette solution and is one of the primary components in the aerosol emitted by e- cigarettes. • Short term exposure causes eye, throat, and airway irritation.5 • Long term inhalation exposure can result in children developing asthma.6 • Even though propylene glycol is FDA approved for use in some products, the inhalation of vaporized nicotine in propylene glycol is not. Some studies show that heating propylene glycol changes its chemical composition, producing small amounts of propylene oxide, a known carcinogen.' • There are metals in e- cigarette aerosol, including chromium, nickel, and tin nanoparticles.8 • FDA scientists found detectable levels of carcinogenic tobacco - specific nitrosamines in e- cigarette aerosol.9 2530 San Pablo Avenue, Suite J • Berkeley, California 94702 • (510) 841 -3032 / FAX (510) 841 -3071 www.no- smoke.org • am @no- smoke.org • People exposed to e- cigarette aerosol absorb nicotine (measured as cotinine), with one study showing levels comparable to passive smokers.'o • Diethylene Glycol, a poisonous organic compound, was also detected in e- cigarette aerosol." • Exhaled e- cigarette aerosol contained propylene glycol, glycerol, flavorings, and nicotine, along with acetone, formaldehyde, acetaldehyde, propanal, diacetin, and triacitine.12 • Many of the elements identified in the aerosol are known to cause respiratory distress and disease. The aerosol contained particles >1 pm comprised of tin, silver, iron, nickel, aluminum, and silicate and nanoparticles ( <100 nm) of tin, chromium and nickel. The concentrations of nine of eleven elements in e- cigarette aerosol were higher than or equal to the corresponding concentrations in conventional cigarette smoke.13 • E- cigarettes cause exposure to different chemicals than found in conventional cigarettes and there is a need for risk evaluation for both primary and passive exposure to the aerosol in smokers and nonsmokers. 14 • Short term use of e- cigarettes has been shown to increase respiratory resistance and impair lung function, which may result in difficulty breathing.15 • Overall, e- cigarettes are a new source of Volatile Organic Compounds (VOCs) and ultrafine /fine particles in the indoor environment, thus resulting in "passive vaping. "'s E- cigarette aerosol is a new source of pollution and toxins being emitted into the environment. We do not know the long -term health effects of e- cigarette use and although the industry marketing of the product implies that these products are harmless, the aerosol that e- cigarettes emit is not purely water vapor. May be reprinted with appropriate attribution to Americans for Nonsmokers' Rights, © 2014 REFERENCES 1 Fuoco, F.C.; Buonanno, G.; Stabile, L.; Vigo, P., "Influential parameters on particle concentration and size distribution in the mainstream of e- cigarettes," Environmental Pollution 184: 523 -529, January 2014. z Grana, R; Benowitz, N; Glantz, S. "Background Paper on E- cigarettes," Center for Tobacco Control Research and Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control. December 2013. 3 Goniewicz, M.L.; Knysak, J.; Gawron, M.; Kosmider, L.; Sobczak, A.; Kurek, J.; Prokopowicz, A.; Jablonska - Czapla, M.; Rosik - Dulewska, C.; Havel, C.; Jacob, P.; Benowitz, N., "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes," Tobacco Control [Epub ahead of print], March 6, 2013. 4 Williams, M.; Villarreal, A.; Bozhilov, K.; Lin, S.; Talbot, P., "Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol," PLoS ONE 8(3): e57987, March 20, 2013. 5 Wieslander, G; Norback, D; Lindgren, T. "Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects." Occupational and Environmental Medicine 58:10 649 -655, 2001. 6 Choi, H; Schmidbauer,N; Spengler); Bornehag, C., "Sources of Propylene Glycol and Glycol Ethers in Air at Home," International Journal of Environmental Research and Public Health 7(12): 4213,4237, December 2010. 7 Henderson, TR; Clark, CR; Marshall, TC; Hanson, RL; & Hobbs, CH. "Heat degradation studies of solar heat transfer fluids," Solar Energy, 27, 121 -128. 1981. 2 8 Williams, M.; Villarreal, A.; Bozhilov, K.; Lin, S.; Talbot, P., "Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol," PLoS ONE 8(3): e57987, March 20, 2013. 9 Westenberger, B.J., "Evaluation of e- cigarettes," St. Louis, MO: U.S. Department of Health and Human Services (DHHS), Food and Drug Administration (FDA), Center for Drug Evaluation and Research, Division of Pharmaceutical Analysis, May 4, 2009. 10 Flouris, A.D.; Chorti, M.S.; Poulianiti, K.P.; Jamurtas, A.Z.; Kostikas, K.; Tzatzarakis, M.N.; Wallace, H.A.; Tsatsaki, A.M.; Koutedakis, Y., "Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function," Inhalation Toxicology 25(2): 91 -101, February 2013. 11 Westenberger, B.J., "Evaluation of e- cigarettes," St. Louis, MO: U.S. Department of Health and Human Services (DHHS), Food and Drug Administration (FDA), Center for Drug Evaluation and Research, Division of Pharmaceutical Analysis, May 4, 2009. 12 Schripp, T.; Markewitz, D.; Uhde, E.; Salthammer, T., "Does e- cigarette consumption cause passive vaping ?," Indoor Air 23(1): 25 -31, February 2013. 13 Williams, M.; Villarreal, A.; Bozhilov, K.; Lin, S.; Talbot, P., "Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol," PLoS ONE 8(3): e57987, March 20, 2013. 14 Pellegrino, R.M.; Tinghino, B.; Mangiaracina, G.; Marani, A.; Vitali, M.; Protano, C.; Osborn, J.F.; Cattaruzza, M.S., "Electronic cigarettes: an evaluation of exposure to chemicals and fine particulate matter (PM)," Annali Di Igiene 24(4):279 -88, July- August 2012. 15 Vardavas, C.I.; Anagnostopoulos, N.; Kougias, M.; Evangelopoulou, V.; Connolly, G.N.; Behrakis, P.K., "Short -term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide," Chest 141(6): 1400 -1406, June 2012. 16 Schripp, T.; Markewitz, D.; Uhde, E.; Salthammer, T., "Does e- cigarette consumption cause passive vaping ?," Indoor Air 23(1): 25 -31, February 2013. 1402 [FS -39] 3 0 fPartnership or Prevention' Shaping Policies • Improving Health Position Statement on E- Cigarettes What are E- Cigarettes? E- cigarettes are battery- powered electronic nicotine delivery systems. They have two primary purposes: to enable the inhaling of nicotine and to imitate the practice of smoking. E- cigarettes do not involve the burning of tobacco or the inhalation of its smoke, but do deliver nicotine which is derived from tobacco. It is generally agreed that they are less toxic than traditional cigarettes and, if all smokers switched to them completely, this would improve public health. It is likely that many people have quit traditional cigarettes by using e- cigarettes, but this information is mostly anecdotal. Is There Cause for Concern? E- cigarettes have not been proven harmless and, as a result, public health organizations and federal agencies are concerned about their risks. They are unregulated products at present, and research on their health effects is in its infancy. Quality control processes used to manufacture e- cigarettes are inconsis- tent and the delivery of nicotine varies significantly. E- cigarette vapor, which has not been proven safe, emits carcinogenic chemicals' and other toxins into the environment. The number of calls to poison cen- ters involving e- cigarette liquids containing nicotine rose from one per month in September 2010 to 215 per month in February 2014.2 What are the Potential Harms of E- Cigarette Use? • They could serve as a gateway for youth to nicotine addiction and tobacco use. • They could re- normalize cigarette smoking in public perception. • , They could discourage or delay tobacco cessation by facilitating dual use. • They could tempt former smokers return to nicotine and potentially relapse to smoking. How Are E- Cigarettes Impacting Youth? • Awareness of e- cigarettes among young people is very high, ranging from 89% for those ages 13 -17 to 94% for young adults ages 18 -21.3 • Use is also high, with 14% of those ages 13 -17 and 39% of those ages 18 -21 reporting having used e- cigarettes. 4 • One study found that 20.3% of middle school students who used e- cigarettes had never smoked traditional cigarettes; thus, they served as their introduction to nicotine.5 • The percentage of high school students who reported ever using an e- cigarette doubled from 2011 to 2012.6 Does Big Tobacco Have a Stake in E- Cigarettes? • Two years ago, the large tobacco companies hadn't made the plunge into the e- cigarette market. Today, Altria, Reynolds, and Lorillard are all deeply invested. • E- cigarette companies aggressively promote their products to young people through celebrities, concerts, sponsorship of youth- oriented events, social media, and free samples.' • E- cigarette ads appeal to kids with flavors like Cherry Crush, Peachy Keen, Gummi Bear, and Cotton Candy. These flavorings are banned in traditional cigarettes. • Kids are exposed to e- cigarettes advertisements on television and via other media. Some states have passed laws prohibiting sales to minors, but e- cigarettes are easy to purchase online. Will the Food and Drug Administration Regulate E- Cigarettes? On April 24, 2014 the Food and Drug Administration released a proposed rule to extend its regulatory authority to e- cigarettes and other products that meet the legal definition of a tobacco product, but are currently unregulated. If the rule becomes final, the newly deemed tobacco products would be required to meet the same standards as currently regulated tobacco products. Under the proposed rule, makers of newly deemed tobacco products would: • Register with the FDA and report product and ingredient listings. • Only market new tobacco products after FDA review. • Only make direct and implied claims of reduced risk if the FDA confirms that scientific evidence supports the claim and that marketing the product will benefit public health. • Not distribute free samples. • Comply with minimum age and identification restrictions to prevent sales to underage youth. • Include health warnings. • Prohibit sales through vending machines, unless in a facility that never admits youth. What is Partnershia for Prevention's Position? In light of these concerns, Partnership for Prevention advocates that: • The Food and Drug Administration move swiftly to finalize the proposed rule regulating e- cigarettes. • All measures are taken to protect children and youth from e- cigarettes including limiting or elimi- nating advertising, minimum age purchase laws, educational campaigns, etc. • Current smokers use evidence -based cessation strategies to quit including FDA - approved medica- tions. • States and communities prohibit the use of e- cigarettes in places where smoking is prohibited. • Renewed efforts are undertaken to normalize nicotine -free lifestyle, working against the glamour and appeal of e- cigarettes which perpetuate the opposite. • A national research program is undertaken to evaluate the harms of e- cigarettes, if any, to the indi- vidual and society (to inform policy decisions). Copyright (0 May 2014 References 1 Kosmider L, et al. "Carbonyl Compounds in Electronic Cigarette Vapors — Effects of Nicotine Solvent and Battery Output Voltage ". Nicotine Tob Res (2014) doi: 10.1093 1ntr/ntuO78. Available here: http: / /ntr.oxfordiournals.org /content /early /2014/05/14/ ntr. ntu078 .full ?sid= b6dlcOda- e3O3 -4aaf- 9754- 6bef9f8c39a4 Z Center for Disease Control and Prevention. "New CDC Study Finds Dramatic Increase in E- Cigarette - Related Calls to Poison Centers ". Morbidity and Mortality Weekly Report. Available here: http: / /www.cdc.goy /mmwr/ preview /iiimwrhtml /mm6313a4.htm 3 Legacy for Health. "Vaporized: E- Cigarettes, Advertising, and Youth ". Available here: http: / /legacyforhealth.ore /content/ down load/ 4542/63436 /version /l /file /LEG- Vaporized -E -cie Repo rt- Mav2014.pdf ° Legacy for Health. "Vaporized: E- Cigarettes, Advertising, and Youth ". Available here: http: / /Iegacvforhealth.org /content/ down load /4542/ 63436 / version /1 /file /LEG - Vapori zed- E -cie Report- Mav2014.pdf 5Centers for Disease Control and Prevention. "Notes from the field: electronic cigarette use among middle and high school students — United States, 2011 - 2012 ". Morb Mortal Wkly Rep. 2013,62:729 -730. Available here: http: /Iwww.ncbi.nlm.nih.gov/ p u b m ed / 24005229? d o pt =Abst ra ct 6Center for Disease Control and Prevention. "E- Cigarette Use More Than Doubles Among U.S. Middle and High School Students From 2011 - 2017'. Morbidity and Mortality Weekly Report. Available here: http: / /www.cdc.gov /mmwr /preview /mmwrhtml/ mm6235a6.htm ' "Gateway to Addiction? A Survey of Popular Electronic Cigarette Manufacturers and Targeted Marketing to Youth. " Available here: http: / /www.durbin.senate.eov/ public /index.cfin /files /serve / ?File id= 81dl4ff7 -f2f6- 4856- af9d- c2OcObl38f8f 10/28/2014 AMERICANS fi "- NONSMOKERS` RIGI ITS Tobacco's Dirty Tricks Get your copy of Bad Acts tudav! Tobacco's Dirty Tricks - no- smoke.org Tobacco companies are the engineers behind the scenes keeping the trains running on time for the opposition in your _own. The problem for Big Tobacco is that it has no credibility with the public. So tobacco companies have developed a system of front groups and allies to allow them to stay_ in the shadows and have others carry their message publicly. The industry then arms these front groups with strategies and tactics to spoil smokefree air campaigns. They have been at it for decades. Big Tobacco and its allies are still hard at work trying to prevent communities from passing smokefree policies. They , alternatives, which even they know will not protect health. They spew c --, i. i,i_ that businesses will lose profits, so that policymakers will be scared away from passing smokefree ordinances. They lobby for pregrr _[ wi laws that strip control away from local governments, where smokefree advocates are most successful. You may say, "But the tobacco industry isn't here in my town." But don't be fooled - the tobacco industry is everywhere. Though you may never EN FRIVOLOUS S�IEN ," LI4 ITS see a tobacco industry representative, they are everywhere that tobaccokRUFiltlN is sold - no town is too small. Big Tobacco's bottom line is at stake in hr every smokefree campaign. Why Does the Tobacco Industry Fight Smokefree Laws? zzw, The bottom line is that smokefree laws result in a ueclme in the S�� ui1suniptiuri of tobacco pr ct ��lus, an increase m the cessation rate among smokers, and an overall decline in the social acceptability of smoking. This all spells bad news for tobacco industry profits and explains why Big obacco is so highly motivated to oppose smokefree laws and to strip away control from local policymakers on this issue. Big Tobacco is fighting a war of attrition to maintain an environment in which its customers can consume its products constantly in any place and at any time. Don't just take http://www.no-smoke.org/getthefacts.php?id=16 1/2 10/28/2014 Tobacco's Dirty Tricks - no- smoke.org our word for it. Here's what Big Tobacco had to say in a once - secret industry document: "Financial impact of smoking bans will tie tremendous - three to five fewer cigarettes per day per smoker will reduce annual manufacturer profits a billion dollars plus per year." "A Smokers' Alliance: draft," Philip Mor-is internal document, July 1, 1993. 2025771995. Now that you have a better idea of why Big Tobacco is so highly motivated to undermine smokefree policies, educate yourself about what to expect. Familiarize yourself with common arguments and how to respond. Learn about Big Tobacco's , and prepare for the ,,u LaL1i the opposition typically uses in the various stages of a smokefree air campaign to stop local activity. http://www.no-smoke.org/gefthefacts.php?id= 16 2/2 AMFRI( -AN N(')NSMOKFRS' RIGI ITS F(_) ._1NDATION U.S. State and Local Laws Regulating Use of Electronic Cigarettes As of October 1, 2014 The following list includes states and municipalities with laws currently in effect that regulate where use of electronic cigarettes (e- cigarettes) is prohibited. E- cigarettes are battery - powered devices that are designed to mimic cigarettes by vaporizing a nicotine -laced liquid that is inhaled by the user. The use of e- cigarettes in workplaces and public places is a significant public health concern, not only because of their unregulated constituents and the potential health impact of the vapor on users and bystanders, but also because e- cigarette use causes public confusion as to where smoking is allowed, resulting in compliance problems with smokefree laws. Most local and state smokefree laws were enacted before e- cigarettes were on the market, so while such laws do not explicitly mention e- cigarettes, it should not be assumed that their use is permitted. Existing smokefree laws are often interpreted to prohibit e- cigarette use in their smokefree provisions. NOTE: In the 100% Smokefree Venues column, the following abbreviations are used: W= non - hospitality workplaces; R= restaurants; B =bars; G= gambling facilities. For more information, please visit ANR's e- cigarettes page. State Laws Regulating Use of E- cigarettes State Laws Restricting E- cigarette Use in 100% Smokefree Venues Other state laws that do not explicitly address e- cigarettes might be interpreted as prohibiting the use of e- cigarettes in existing smokefree provisions. State 100% Smokefree Venues in Which Use Use of E- cigarettes Permitted In: of E- cigarettes Prohibited Specifically Permitted 1. North WRBG No Dakota 2. New 1WRB 'No Jersey 3. Utah WRB !Yes Retailers that sell e- (cigarettes, until 7/1/17. State Laws Regulating E- cigarette Use in Other Venues State Prohibited In: Use of E- cigarettes I If Partial, Permitted In: Specifically Permitted 1. Arkansas Use of a -ci arettes rohibited on No g P school district property. 2530 San Pablo Avenue, Suite J - Berkeley, California 94702 - (510) 841 -3032 / FAX (510) 841 -3071 www.no - smoke.org - am @no - smoke.org Page 1 of 9 State I Prohibited In: ISpecifically Use of E- cigarettes If Partial, Permitted In: Permitted 2. Colorado 3. Delaware 4. Hawaii 5. Kansas 6. Maryland 7. New Hampshire 8. Oklahoma 9. Oregon 10. South Dakota !Definition of tobacco product for No purposes of prohibitio-i of use on school property amended to include e- cigarettes, unless approved by FDA as :cessation devices. iTobacco use, including use of e- 1No Icigarettes and hookahs, prohibited in fall State workplaces, including all buildings, facilities, indoor and outdoor i jspaces and surrounding grounds, as !well as parking lots and state vehicles operated on State workplace property. JUse of e- cigarettes prohibited on all No !Dept. of Health property where smoking is prohibited. ',Tobacco use, includin €; use of e- !Partial cigarettes, prohibited on all Dept. of Corrections property and grounds, by ,both employees and inmates. Per ;opinion of Attorney General, Indoor !Clean Air Act of 2010 does not apply to e- cigarettes. ,Smoking, including use of e- cigarettes No ;prohibited on MARC commuter rail !system trains. ;Use of e- cigarettes prohibited in public �,No !educational facilities and on grounds !thereof. Tobacco use, including; use of e- No ,cigarettes, prohibited in all Dept. of 'Corrections facilities, including vehicles 'and grounds. !State agency employees prohibited No ;from using tobacco products, including ,e-cigarettes, in State agency buildings ;and on State agency grounds adjacent to buildings. Tobacco use, including; use of e- !No ;cigarettes, prohibited in Dept. of Corrections facilities and on grounds ithereof, by both employees and !inmates. Page 2 of 9 ;All places where smoking is ,prohibited per 3/12/10 law, 'including workplaces, !restaurants, bars, gambling !facilities, and public places ',generally. State I Prohibited In: _ — — -- — - 11. Vermont Smoking, including use of e- cigarettes, prohibited on school grounds and at child care facilities, both indoors and loutdoors. Use of E- cigarettes Specifically Permitted No If Partial, Permitted In: Local Laws Regulating Use of E- cigarettes , Laws Restricting E- cigarette Use in 100% Smokefree Venues Note: The iurisdiction(s) affected by county -level laws vary widely. Look for a plus symbol ( +) next to each county with a law that includes both incorporated and unincorporated areas. A county without a symbol means that the county law covers unincorporated areas only. 1. AK 100% Smokefree IRBG No State City /County Venues in Which Use of E- cigarettes If Partial, Permitted In: 3. AL Use of E- cigarettes Specifically Permitted No 4. AL Prohibited !WRG No 1. AK Juneau IRBG No 2. AK Palmer !WRB No 3. AL Anniston (WRBG No 4. AL Bessemer !WRG No 5. AL Clay jWRBG No 6. AL Creola 1WRBG No 7. AL Foley jWRG No 8. AL Fultondale jWRBG No 9. AL Midfield jWRBG No 10. AL Monroeville !WRBG No 11. AL Troy WRBG No 12. AL Vestavia Hills jWRBG No 13. AZ Coconino County !WR No 14. AZ Tempe IWRB No 15. CA Arcata 'WRB No 16. CA Beverly Hills IRBG No 17. CA Campbell RBG No 18. CA Carlsbad !RBG No 19. CA Contra Costa County ;WRBG No 20. CA !Corte Madera IWRB No 21. CA Davis "k- RBG No 22. CA Del Mar jFW RB No Page 3 of 9 23. CA (Dublin 10D% Smokefree 24. CA IEureka State City /County Venues in Which Use of E- cigarettes If Partial, Permitted In: No Fremont Use of E- cigarettes Specifically Permitted Goleta 28. CA 'No Prohibited 29. CA _jLos 23. CA (Dublin WRB 24. CA IEureka No 25. CA No JFairfax 26. CA No Fremont 27. CA No Goleta 28. CA 'No [Long Beach 29. CA _jLos Angeles 30. CA !theatrical jManhattan Beach 31. CA `No Marin County 32. CA ;Mill Valley 33. CA (Morgan Hill 34. CA Mountain View 35. CA 'Oroville 36. CA !Petaluma 37. CA !Richmond 38. CA ;San Bernardino 39. CA San Francisco 40. CA 'Santa Clara County 41. CA !Santa Maria 42. CA !Seal Beach 43. CA "Sebastopol 44. CA ;Solana Beach 45. CA Temecula 46. CA 'Tiburon 47. CA ,Union City 48. CA Walnut Creek 49. CO !Edgewater 50. CO (Lakewood 51. FL Alachua County 52. FL ,Clay County 53. FL Lighthouse Point 54. FL 'Marion County 55. FL (Orange Park 56. GA Chatham County 57. GA DeKalb County ,RBG iNo WRB WRBG No No ;WRBG No W ;WRB No !No IRB No WRES FWRB,G 'No _ (No 'RBG 'Partial lRetail e- cigarette stores and INo !theatrical production sites. iWREG `No WRIIG WR6 (Partial lindividual apartment units in ;WRB Imulti -unit residences. WRE No WRB iNo WREN No �W 'No W No WRBG !No ;W No WRES INo ;WRE9 _ (No ;RB !No RBG INo ,WRBG ;No RB iNo WRIIG No (WRB iNo ;WRB INo RBG 'No WRBG ;No RBG !No �WRG INo WR - INo WRG 'No WRG lNo WRG iNo WR13G lNo W !No Page 4 of 9 100% Smokefree State City /County Venues in Which Use of E- cigarettes Prohibited Use of E- cigarettes Specifically Permitted If Partial, Permitted In: 58. GA Savannah ,WRBG 1N0 59. ID Ketchum WRBG No 60. IL 'Arlington Heights WR jNo 61. IL Chicago WRBG Partial 62. IL Evanston I WRB No 63. IL Schaumburg IWRBG No 64. IN Indianapolis /Marion V B No 65. KY Bardstown WRBG No 66. KY Berea WRBG No 67. KY Glasgow RBG No 68. KY Kenton W No 69. KY Madison WRBG No 70. KY Manchester iWRBG No 71. LA Cheneyville IWRBG No 72. LA Monroe IWRBG No 73. LA Ouachita Parish (WRBG No 74. LA West Monroe IWRBG No 75. MA Acton 1WRBG No 76. MA Adams IWRBG No 77. MA Amherst _ - IWRBG No 78. MA Arlington WRBG No 79. MA Athol !WRBG No 80. MA Auburn IWRBG No 81. MA Barre ;WRBG No 82. MA Bolton -�� !WRBG No 83. MA Boston WRB No 84. MA Bourne !WRB No 85. MA Buckland WRBG No 86. MA Burlington IWRBG No 87. MA Dedham WRB No 88. MA Deerfield IWRBG No 89. MA Dighton - IWRBG No 90. MA _ jDover IRB No 91. MA - - - - -- TDracut -- jWRBG No 92. MA Easthampton jWRBG No 93. MA Fitchburg IWRBG No Page 5 of 9 (Theater performances; retail tobacco stores. State I City /County 194. MA MA Haverhill IFoxborough 95. MA No No Franklin 196. MA �- r - - - -- bars and Gardner __ 97. M_ A Partial Gill �98. MA 104. Grafton 99. MA FGreat Barrington 100. MA lGreenfield 101. MA I CHatfield 100% Smokefree Venues in Which Use of E- cigarettes Prohibited - _ - - -.__ WREIG WRBG - - -- WREIG WRBG WRBG WRBG WRBG WRBG Use of E- cigarettes Specifically Permitted If Partial, Permitted In: No MA Haverhill No INo No No No �- r - - - -- bars and IN ov- !No - (Smoking Partial - - - -� hotels /motels. 102. MA Haverhill WRBG INo 103. MA Hudson WRBG 'No - - - -� 104. MA Lee WRBG !No 105. MA Leicester WRBG jNo 106. MA Lenox JWRBG lNo 1107. MA Lynn WRBG �No 108. MA Marblehead WWRBG �No 109. MA Medway WRBG �No 110. MA Montague WRBG 'No 111. MA Needham WR13 'No 112. MA New Bedford WR13G iNo 113. MA Newton WR13G INo 114. MA North Attleborough WR13G �No 115. MA Northampton WR13G N.o 116. MA lOrleans WR13G [No 117. MA Oxford WRBG �No 118. MA Pittsfield WRBG No 119. MA (Salem WR13G No T 120. MA Saugus WRBG No 121. MA Sharon WR13G No T 122. MA Shelburne WR13 Wo 123. MA Somerset WR'3G INo 124. MA .South Hadley WR3G No 125. MA ,Stockbridge WR3G No T 1126. MA (Sunderland WR3G No 1127. MA JSutton WRBG No T '128. MA Swampscott WRBG No 129. MA Taunton WR3G No C•, Page 6 of 9 H 130. MA 100% Smokefree IWRBG State City /County Venues in Which Use of E- cigarettes Use of E- cigarettes Specifically Permitted If Partial, Permitted In. 'WRBG No Prohibited MA 130. MA Townsend IWRBG jNo 131. MA Wendell 'WRBG No 132. MA Westminster IWRBG No 133. MA Westport jWRBG No 1134. MA (Westwood WRBG No 135. MA Weymouth WRBG No 136. MA hately WRBG No 137. MA 'Winchester \A 'No 138. MN Duluth - -WRBG INo 139. MN Eden Prairie 'WRBG No 140. MN Ely jWRBG No 141. MN Hermantown -'- jWRB No 142. MN Houston County WRBG No 143, MN Mankato WRB No 144. MN Waseca IWRBG No 145. MO Creve Coeur jWRB No 146. MO Jefferson City A- IWRBG No 147. MO St. Joseph 'WRBG No 148. MO Washington �- IWRBG No 149. MS Anguilla ;WRBG No 150. MS Arcola WRBG No 151. MS Baldwyn WRBG No 152. MS Bassfield WRBG No 153. MS Bruce WRBG No 154. MS Byram WRBG No 155. MS Calhoun City WRBG No 156. MS Centreville WRBG No 157. MS jCoahoma County WRB No 158. MS Crawford ';WRBG No 159. MS Duncan WRBG No 160. MS Durant WRBG No 161. MS Ethel ;WRBG No 162. MS Farmington WRBG No 163. MS Flowood WRG No 164. MS Forest jWRBG No 165. MS Friars Point WRBG No 166. MS Georgetown WRBG No Page 7 of 9 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. MS !Indianola 100% Smokefree Partial State City /County Venues in Which Use of E- cigarettes If Partial, Permitted In: Itta Bena WRBG Use of E- cigarettes Specifically Permitted No �rr No Prohibited Louisville 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. MS !Indianola +WRBG Partial No NY Suffolk MS Itta Bena WRBG OH No �rr No MS Louisville ,WRBG INo No WRB OR MS ;Magee ;WRBG INo PA !Philadelphia CWRB MS :Mendenhall 'WRBG INo MS !Monticello ,RBG ___fNo MS IMoorhead WR13G INo MS !New Augusta WRBG MS Plantersville ;WRBG �No MS Prentiss 'WRBG !No MS 'Rolling Fork ;WRBG INo MS Sledge WR13G INo MS Southaven WR13 INo - MS Sumner WRBG No MS Walnut WR3G ----- - - - INo - -- - -- - MS Wesson WR3G INo MS Woodville WRBG !No ND Bismarck WRBG ''No ND Walhalla WRBG No -- NM Santa Fe WRB No NY Cattaraugus County RBG No NY New York City WRB Partial Retail e- cigarette stores. NY Suffolk WRB No SC OH !Oberlin :WRB No Yemassee OR ;Benton County _jWRB No WRB OR Corvallis WRB INo 200. PA !Philadelphia CWRB Partial Specialty e- cigarette 194. SC ! :Denmark (WRB 195. SC :Estill ,WRBG 196. SC West Pelzer !WRB 197. SC Yemassee !WRB 198. TX ,Frisco WRB 199. TX Harlingen -+WRBG 200. TX Joshua _)MR !establishments; tobacco products distribution businesses. No No 'No No No No -� No Page 8 of 9 0 201. TX 100% Smokefree WRBG No State City /County Venues in Which Use of E- cigarettes If Partial, Permitted In: 203. TX Use of E- cigarettes Specifically Permitted No 204. TX Prohibited 1WRB No 201. TX Lufkin WRBG No 202. TX San Angelo WRB No 203. TX San Marcos WRB No 204. TX Socorro 1WRB No 205. TX Waxahachie v WRBG No 206. TX Weatherford �R No 207. TX Wichita Falls IWRB No 1208. WA King IWRBG No 209. WA Pasco IWRBG No 210. WI Ashwaubenon 1WRBG No 211. WV Berkeley WRBG No 212. WV Calhoun IWRBG No 213. WV Greenbrier a `WRBG No 214. WV Lewis IWRBG No 215. WV Marshall W No 216. WV Mineral IWRBG No 217. WV Pleasants A ;WRBG No 218. WV Randolph IWRBG No 219. WV Ritchie ;WRBG No 220. WV Roane ;WRBG No 221. WV Taylor County IWRBG No 222. WV Upshur jWRB No 223. WV Webster WR No 224. WV Wirt WRBG No 225. WV Wood WRBG No 'Law pertains to both incorporated and unincorporated areas of county. Laws Currently in Effeo State Laws Restricting E- cigarette Use in 100% Smokefree Venues: 3 State Laws Restricting E- cigarette Use in Other Venues: 11 Local Laws Restricting E- cigarette Use in 100% Smokefree Venues: 225 In addition, 121 local laws restrict E- cigarette Use in Other Venues (not listed above) Copyright 1998 - 2014 American Nonsmokers' Rights Foundation. All rights reserved. Page 9 of 9 Page 1 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164 /rccm.201407- 1198PP on Electronic Cigarettes: A position statement of the Forum of International Respiratory Societies Dean E. Schraufnagell, MD, Francesco Blasi2, MD, M. Bradley Drummond3, MD MHS, David C. L. La M4, MBBS, PhD, Ehsan Latifs, MD, Mark J. Rosen 6, MD, Raul Sansores7, MD, and Richard Van Zyl- Smitg, MD, PhD on behalf of the Forum of International Respiratory Societies. Author Affiliations: 1 Pulmonary, Critical Care, Sleep and Allergy Department, University of Illinois at Chicago, Chicago, Illinois; 2 Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ca Granda, Milano, Italy; 3 Pulmonary /Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; 4 Department of Medicine, University of Hong Kong, Hong Kong SAR, China; 6 'Department for Tobacco Control, International Union Against Tuberculosis and Lung Disease -UK, Edinburgh, United Kingdom; 6 American College of Chest Physicians, Glenview, Illinois; 7 Departamento de Investigacion en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Repiratorias Ismael Cosio Villegas, Mexico City, Mexico; 8 Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa. The Forum of International Respiratory Societies (FIRS) is comprised of professional organizations and experts in respiratory disease around the world. The member societies include Asociaci6n Latinoamericana del Thorax (ALAT), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), the Asian Pacific Society of Respirology (APSR), the European Respiratory Society (ERS), the International Union Against Tuberculosis and Lunp Disease (The Union), and the Pan African Thoracic Society (PATS). The goal of FIRS is to promote global respiratory health. Copyright CO 2014 by the American Thoracic Society AJRCCM Articles in Piess. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP Pag6 2 of 27 Correspondence may be addressed to: Dr. Dean E. Schraufnagel — University of Illinois at Chicago, 840 S. Wood St. (MC 719), Chicago, Illinois 60612 -7323, United States Phone: 312 - 996 -8039 Email: schrauf @uic.edu To see author disclosures, please access the online data supplement related to this manuscript, available online at www.atsiournals.org. June 30, 2014, V16 Copyright CO 2014 by the American Thoracic Society Page 3 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1 164/rccm.201407 -1 198PP ABSTRACT: Background: Awareness and usage of electronic cigarettes has exponentially increased during the last few years, especially among young people and women in some countries. The rapid acceptance of electronic cigarettes may be attributed in part to the perception created by marketing and the popular press that they are safer than combustible cigarettes. Goals: To alert and advise policy makers about electronic cigarettes and their potential hazards. Methods: Using the Union's position paper on electronic cigarettes as the starting template, the document was written using an iterative process. Portions of the manuscript have been taken directly from the position papers of participating societies. Results: Since electronic cigarettes generate less tar and carcinogens than combustible cigarettes, use electronic cigarettes may reduce disease caused by those components. However, the health risks of electronic cigarettes have not been adequately studied. Studies looking at whether electronic cigarettes can aid smoking cessation have had inconsistent results. Moreover, the availability of electronic cigarettes may have an overall adverse health impact by increasing initiation and reducing cessation of combustible nicotine delivery products. Conclusions: The health and safety claims regarding electronic nicotine delivery devices should be subject to evidentiary review. The potential benefits of electronic cigarettes to an individual smoker should be weighed against potential harm to the population of increased social acceptability of smoking and use of nicotine, the latter of which has addictive power and untoward effects. As a precaution, electronic nicotine delivery devices should be restricted or banned until more information about their safety is available. If they are allowed, they should be closely regulated as medicines or tobacco products. Copyright cci 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09- July -2014 as 10.1164 /rccm.201407- 1198PP Page 4 of 27 TABLE OF CONTENTS Overview Introduction Awareness and Prevalence of Use Safety Harm Reduction of Electronic Cigarettes The Premise Health Effects of Nicotine Electronic cigarettes as an aid to smoking cessation and tobacco -use reduction Comparative Effects with Combustible Cigarettes Regulation and legislative responses to electronic cigarettes World Health Organizat on Framework Convention on Tobacco Control Positions on Electronic Nicotine. Delivery Devices Summary 4 Copyright CO 2014 by the American Thoracic Society Page 5 Of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164,lrccm.201407-1198PP OVERVIEW "Electronic cigarettes" or "electronic nicotine delivery systems," are devices that deliver to the lung vapors usually containing nicotine and other chemicals. The appeal to users and primary concern for health advocates is nicotine, which is highly addictive. Electronic cigarettes generate less tar and carcinogens than combustible cigarettes, but information sufficient enough to evaluate these products is lacking. Studies have shown that individuals who do not intend to quit smoking can reduce their intake of combustible cigarettes with electronic cigarettes, but other studies have failed to show superiority of e- cigarettes over nicotine replacement medicine or placebo for individuals trying to stop smoking. A public health concern is that the use of these products may increase the risk of non - smokers developing nicotine dependence and of current smokers maintaining their dependence. The gravity of tobacco use on global health, the intensity of the nicotine addiction, and the historical behavior of the tobacco industry have prompted governments and health advocates to take a cautious approach to these products. The position of the Forum of International Respiratory Societies (FIRS) on electronic nicotine delivery devices includes: The health risks of electronic cigarettes have not been adequately studied. The addictive power of nicotine and its untoward effects should not be underestimated. The potential benefits of electronic nicotine delivery devices, including harm reduction and as an aid to smoking cessation, have not been well studied. Potential benefits to an individual smoker should be weighed against harm to the population of increased social acceptability of smoking and use of nicotine. Health and safety claims regarding electronic nicotine delivery devices should be subject to evidentiary review. Adverse health effects for non - smokers exposed to the emissions of electronic cigarettes cannot be excluded. Electronic nicotine delivery devices should be restricted or banned, at least until more information about their safety is available. Copyright O 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164lrccm.201407 -1 198PP Page s Of 27 If electronic nicotine delivery devices are permitted, they should be regulated as medicines and subject to the sarne evidentiary review of other medicines. If electronic nicotine delivery devices are not regulated as medicines, they should be regulated as tobacco products. Research, supported by :sources other than the tobacco or electronic cigarette industry, should be carried out to determine the impact of electronic nicotine delivery devices on health in a wide variety of settings. The patterns of use and the consequences at the population level of electronic nicotine delivery devices should be monitored. All information derived from this research should be conveyed to the public in a clear manner. INTRODUCTION "Electronic cigarettes" are devices that vaporize and deliver to the lungs a chemical mixture usually composed of nicotine, propylene glycol, and other substances. The appeal to users and concern from health advocates stems from the delivery of highly addictive nicotine via a non - combustible product. The devices are also referred to as "electronic nicotine delivery systems," although this is not precise because they can be engineered not to deliver nicotine. "Electronic cigarettes' is also not a precise term. Although most "electronic cigarettes" are shaped to look like their combustible tobacco counterparts (e.g. cigarettes, cigars, cigarillos, pipes, hookahs or shishas), they may also be made to look like everyday items, such as pens and USB memory sticks, for people who wish to use the product without other people noticing (1). In this publication, we use terms "electronic cigarettes" and "electronic nicotine delivery devices" almost interchangeably, although "electronic cigarettes" is the more popular term for these devices and "electronic nicotine delivery systems" is the more formal, scientific, and legal term. Copyright © 2014 by the American Thoracic Society Page 7 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164%rccm.201407- 1198PP Electronic cigarettes were first produced in China in 2003 and are now available globally (2), However, the Legacy Tobacco Documents Library also showed that the Philip Morris company experimented with electronic cigarettes as early as the 1990s (3). The devices contain an electronic vaporization system, batteries, electronic controls and cartridges of the liquid that is vaporized. When activated by the user, the heating element vaporizes the liquid that produces a visible cloud that is inhaled. Electronic cigarettes almost always contain nicotine and flavorings. These may taste like candy, and could be especially attractive to children or adolescents. Indeed, marketing of e- cigarettes has been directed at the young adults and children according to US Food and Drug Administration documents (4). AWARENESS AND PREVALENCE OF USE In a short period, awareness has increased and use of electronic cigarettes has spread rapidly and extensively. In a consumer - based, mail -in survey of 10,587 adults in 2009 and 10,328 adults in 2010, awareness of electronic cigarettes doubled from 16.4% in 2009 to 32.2% in 2010. At the same time, the number of people who had tried electronic cigarettes more than quadrupled, from 0.6% in 2009 to 2.7% in 2010. Trying electronic cigarettes was common among women and those who were less educated, although these were not the groups who were most aware of them. Current smokers were most likely to use these devices (5). Similar increasing awareness and usage of electronic cigarettes also has been reported in other large surveys (6) (7). Copyright T, 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP page 8 Of 27 A well- designed four - country survey reported the prevalence of electronic cigarette use in the United States (US), United Kingdom (UK), Canada, and Australia (2). Overall, 46.6% of respondents were aware of electronic cigarettes (US: 73 %, UK: 54 %, Canada: 40 %, Australia: 20 %). Of all persons surveyed, 7.6% had tried them, but 16% of persons who were aware of them had tried them. Overall, 2 9% were current users of e- cigarettes, but 39% of those who had tried them were current users. Younger persons, non - minority smokers, those with higher incomes, and heavier smokers were most aware of electronic cigarettes. Persons who were younger, had higher incomes, and perceived electronic cigarettes as being less harmful than combustible cigarettes were more likely to try them. In all, 79.8% of smokers who reported using electronic cigarettes did so because they considered them less harmful than combustible cigarettes; 75.4% stated that they used them to reduce their smoking; and 85.1% reported using them to quit smoking (2). The Global Adult Tobacco Survey 2011 for Indonesia showed that overall, 10.9% of adults were aware of electronic cigarettes, but only 0.3% used them (8). A recent review found that 10% of UK smokers used electronic nicotine delivery devices; the number of users rose to around 1.3 million in 2013, up from 700,000 the previous year (9). In September 2013, the United States Centers for Disease Control and Prevention reported that e- cigarette use had doubled among middle and high school students from 2011 to 2012, resulting in an estimated 1.78 million students who had tried them by the end of 2012. Moreover, an estimated 160,000 students who reported trying electronic cigarettes had never used combustible cigarettes. Health authorities are concerned that nicotine may have a negative impact on adolescent brain development and increase the risk for nicotine Copyright n 2014 by the American Thoracic Society Page 9 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP addiction that could lead to the use of tobacco products (10). Increased use, especially among youth, has raised serious concerns about the overall impact of e- cigarettes on public health. Many public health and government groups have published statements or policies opposing or restricting their use. These have been reviewed in a statement by the International Union Against Tuberculosis and Lung Disease (11). SAFETY The nicotine delivered in tobacco products is highly addictive and in excessive amounts (0.5- 1.0 mg per kg body weight for adults and 0.1 to 0.2 mg /kg for children) can be lethal. Manufacturers of e- cigarettes report that each replacement cartridge typically contains between 6 and 24 mg of nicotine, but some may contain more than 100 mg. To the degree that these products are not regulated or monitored, there is considerable variation in their contents, even within the same product. (1, 9). Furthermore, the contents of these products are unknown to the consumer. Even if the product consistency became constant, the safety of electronic nicotine delivery devices has not been demonstrated (1), (12), (13), (1, 14). Replacement cartridges pose a risk for nicotine poisoning. For example, a 30- kilogram child who swallows the contents of a 24 -mg nicotine cartridge is at high risk of developing acute and lethal nicotine poisoning (1). Nicotine, whether inhaled, ingested, or in direct contact with the skin can be particularly hazardous to the health and safety of certain segments of the population including children, young people, pregnant women, nursing mothers, people with heart disease, and the elderly. Cartridges and other refill accessories could be also ingested by young children and result in choking (15, 16). Copyright n 2014 by the American Thoracic Society AJRCCM Articles in Piess. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP Page 10 of 27 Most electronic nicotine delivery devices contain large concentrations of propylene glycol, which is a known irritant when inhaled. Little is known about the health impact of long -term inhalation of propylene glycol. Tests by United States Food and Drug Administration revealed the presence of diethylene glycol, a chemical that has a history of mass poisonings and deaths when inadvertently substituted for propylene glycol in consumer products (17). The exact ingredients of electronic cigarettes are unknown but the effects of ingredients that may be found in them should be identified and studied. This includes the effects of inhalation of irritants, solvents, genotoxins, and animal carcinogens (e.g., butyl acetate, diethyl carbonate, benzoic acid, quinoline, dioctyl phthalate 2,6- dimethyl phenol) (17). Because electronic cigarettes do not generate the smoke that is produced by combustion of tobacco, their use is commonly believed by consumers to be safer than smoking tobacco. However, the chemicals they contain have not been fully disclosed and the safety is not assured. Several studies involving human subjects (18 -21) and other experimental models (22 -24) underline concerns about toxicity, lack of safety information, and product design flaws that may have negative health consequences. These include the presence of toxic metals (cadmium, nickel, lead) and silicates in the e- cigarette vapor, although these are present at a lower level than found in combustible cigarettes (25). The current state of the design and manufacture of electronic nicotine delivery devices lacks quality control of toxic elements (26), nicotine dose (18), the presence of propylene glycol and other chemicals, and consistency of contents. The refill fluids may have cytotoxic prenatal effects (22). There is limited information about the effects of electronic nicotine delivery systems on lung 10 Copyright © 2014 by the American Thoracic Society Page 11 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP function (19). There is a lack of adequate labeling and absent or misleading information on product ingredients (20, 23). The sensation of inhaling e- cigarette aerosol may be less satisfying than from tobacco, leading to faster and deeper inhalation, which may also affect health adversely (21, 24). These issues have led experts to call for close regulation of electronic nicotine delivery devices (21). Finally, there is concern that the material exhaled by users may be inhaled by others, especially indoors. Passive inhalation of the vaporized fine and ultrafine inhalable droplets and particles, nicotine, and cancer - causing substances into indoor air may have significant adverse health effects (27). HARM REDUCTION OF ELECTRONIC CIGARETTES The premise Electronic cigarettes do not produce the tar that is associated with tobacco smoke, which may be the major cause of bronchitis, emphysema, and lung cancer. Therefore, the premise is that replacing combustible with electronic cigarettes reduces the harm caused by combustible cigarette smoking. Furthermore, electronic cigarettes could be used as medical nicotine replacement products in promoting smoking cessation (28). Health effects of nicotine (29) 11 Copyright ^ 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09- July -2014 as 10. 1 164/rccm.201407-1198PP page 12 of 27 The harm - reduction premise ignores the deleterious effects of nicotine. Nicotine is highly addictive (30) and affects many body cells, mediators, and metabolic pathways (31). It has long been known to adversely affect children, not only in utero, but also during postnatal development through adolescence. It may even cause adult disease. There is evidence that in utero exposure influences the later occurrence of conditions such as impaired fertility, type 2 diabetes, obesity, hypertension, neurobehavioral defects, and respiratory dysfunction (32). Nicotine has significant cardiovascular effects (33) (34) and may play a major role in the development of coronary artery disease (35), atherosclerosis (36), and aortic aneurysms (37). Nicotine affects neuroregulation and structural changes in the brain and lung that could disturb a w de variety of reflexes and responses; these changes could increase vulnerability to hypoxia (38). Nicotine has been associated with the development of peptic ulcer and gastrointestinal cancer (39), may promote tumour angiogenesis (40) and may alter neurologic development (41). Nicotine addiction may cause deleterious effects in women's brains by inhibiting estrogen signaling, which in turn may make the brain more susceptible to ischemia (42). There are many reports of the deleterious effect of nicotine on bones in both animal models and humans (43) and of the adverse effect of nicotine on chromosomes ( "genotoxic effect') of fetal cells (44). However, medicinal nicotine as an aid to smoking cessation has a good safety record. The doses of nicotine and its release mechanisms have been tested and standardized. These medicines have been approvec by regulatory agencies after extensive study. The hazards of 12 Copyright n 2014 by the American Thoracic Society Page 13 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164/rccm.20 1 407- 1 1 98PP electronic cigarettes are that they have not been adequately tested, standardized, or regulated as nicotine delivery systems and, therefore, their safety is uncertain. Electronic cigarettes as an aid to smoking cessation and tobacco -use reduction Studies of the effectiveness of electronic cigarettes as an aid to smoking cessation differ from studies that have an endpoint of reducing tobacco use. In a study designed to evaluate smoking reduction and abstinence in 300 smokers who did not intend to quit, two different nicotine strengths of a popular Italian e- cigarette model ('Categoria'; Arbi Group Sri, Italy) were compared with a non - nicotine e- cigarette. All three groups had a reduction in the number of combustible cigarettes smoked per day and there was no consistent difference between groups. There were no significant side effects (45). The same authors also published a prospective, observational study that found more than a 50% smoking reduction, also in smokers who did not intend to quit. However, 17 of the 40 subjects were lost to follow -up at 24 months. Despite the 42% drop -out rate, the investigators concluded that long -term e- cigarette use is well - tolerated and can substantially decrease combustible cigarette consumption in smokers not planning to quit (46). In a controlled trial conducted in New Zealand, 657 smokers were randomized (289 to nicotine e- cigarettes, 295 to nicotine patches, and 73 to placebo e- cigarettes) and compared with an intention -to -treat analysis. At 6 months, verified abstinence was 7.3% (21 of 289) with nicotine e- cigarettes, 5.8% (17 of 295) with patches, and 4.1% (3 of 73) with placebo e- cigarettes. The relative risk of achieving abstinence for nicotine e- cigarettes was 1.51 compared with nicotine patches and 3.16 compared with placebo. Achievement of 13 Copyright c; 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164/rccm.201 407- 1 1 9 8PP page 14 of 27 abstinence was substantially lower than the researchers anticipated for the sample size calculations. Thus, the study was unable to conclude superiority of nicotine e- cigarettes to patches or placebo, nor did it show significant differences in adverse events among the groups (47). A cross - sectional survey of 1,835 current or recently -quit adult smokers found that 38% had tried an alternative tobacco product, most frequently electronic cigarettes, but the electronic cigarettes were not associated with successful quit attempts (48). A survey of 3,240 individuals, which found never- smokers and former - smokers had tried these products, concluded with conce rn that electronic cigarettes could increase the risk of non- smokers developing nicotine dependence and of current smokers maintaining their dependence (49). The four - country survey, cited earlier, found nearly three quarters (70.4 %) of those sampled used electronic nicotine delivery devices to obtain nicotine in smoke -free spaces, indicating that electronic cigarettes were being used also to satisfy nicotine addiction during periods of temporary cigarette smoking abstinence. Current electronic cigarette use was associated with a greater reduction in cigarettes per day over time, compared to those who did not use them. However, electronic cigarettes users were not more likely to quit smoking than those who did not use them (2). Other studies have not shown significant benefit of using electronic nicotine delivery devices for smoking cessation (50) (51). 14 Cop,/right t, 2014 by the American Thoracic Society Page 15 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164hccm.20 1 407- 1 1 98PP Comparative effect versus combustible cigarettes Current information suggests that for an individual, use of electronic cigarettes would reduce overall health risk compared with smoking combustible cigarettes (52). However, for a population, the availability of electronic cigarettes may have an overall adverse impact by increasing initiation and reducing cessation of smoking (29). Electronic cigarettes could lead to an increase in nicotine use and dependence, and be a gateway to combustible tobacco products. Alternatively, electronic cigarettes could lead to a reduction in combustible cigarette use among established smokers, potentially leading to incremental health benefits regarding tobacco - related morbidity. More study is needed with careful tracking of what is happening in populations where electronic cigarettes are available. REGULATION AND LEGISLATIVE RESPONSES TO ELECTRONIC CIGARETTES The gravity of the adverse effects of tobacco use on global health (53) and the historical behavior of the tobacco industry that has included deceit about the health effects of tobacco, intentional marketing to children, and manipulating nicotine levels in cigarettes to maintain or increase addiction (54) has prompted governments, health officials, and health advocates to monitor and censure the tobacco industry. The tobacco industry has spent enormous sums of money and manipulated information to influence health care policy through its advertising strategy (55). It has marketed filtered and "low -tar' cigarettes as "healthier" and "safer' alternatives without adequate scientific evidence. Use of these products inevitably resulted in untold suffering and premature death for millions of people 15 Copyright (� 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP Page 16 of 27 worldwide. Because nicotine is central to the lifelong addiction, and because these are nicotine delivery instruments, careful investigation and regulation of these products are required. Many governments have chosen to restrict the sale of nicotine delivery systems, or to ban them entirely. On February 26, 2014, the European Commission Directive issued a strong statement about electronic cigarettes and their safety (56). Electronic cigarettes and other electronic products containing nicotine are to be regulated as medicines in the UK from 2016 onward; the move comes after an investigation into the products by the Medicines and Healthcare Products Regulatory Agency (57). However, the Agency's plans are aligned with forthcoming European legislation stipulating that electronic nicotine delivery devices would not be required to obtain a medicine license until the European Commission's Tobacco Products Directive agrees. The revision of the European Commission's Directive is expected to address the following main issues: how to regulate products that do not contain tobacco, but which are closely linked to smoking or tobacco consumption, such as electronic and herbal cigarettes; • labelling and packaging of tobacco products; • additives, such as flavorings, used in tobacco products; • internet sales of tobacco products; and • tracking the use of these products. This contrasts with actions in o-.her countries that introduced restrictions on the sale and use of electronic nicotine delivery devices. Brazil, Norway, Singapore, and Indonesia have banned them completely (57); the Food and Drug Monitoring Agency of Indonesia has 16 Cop.iright n 2014 by the American Thoracic Society Page 7 Of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164 /rccm.20 1407- 1 1 98PP warned that electronic cigarettes could be more dangerous than combustible cigarettes (58). In the Philippines, the Food and Drug Administration issued an advisory notice on secondary exposure to electronic nicotine delivery device emissions. Citing the review published by the German Cancer Research Centre (27), the advisory states that the possibility that "Second- hand exposure to e- cigarette emission may lead to adverse health effects cannot be excluded." It goes on to recommend that, "The public, especially the youth sector, is advised NOT to start smoking at all and to stop using cigarettes, cigars or electronic nicotine delivery devices." The Consumer Act of the Philippines strengthened local ordinances against smoking in public places and on second -hand exposure to harmful substances (59) (60). On April 24, 2014 the United States Food and Drug Administration (FDA) Center for Tobacco Products proposed regulations that would ban the sale of electronic cigarettes to minors, require manufacturers to register with the FDA, and give a detailed accounting of the ingredients. The packages would have to have labels warning that nicotine is addicting, but the rules would not outlaw flavors or advertising (61). World Health Organization Framework Convention on Tobacco Control The Framework Convention on Tobacco Control is a treaty developed by the World Health Organization and the World Health Assembly in 2003 to control tobacco use worldwide (62). The treaty came into force in 2005 and is legally binding in the 178 ratifying countries. It is updated regularly, and the Conference of the Parties to the treaty published a report in June 17 Copyright n 2014 by the American Thoracic Society AJRCCM Articles in Piess. Published on 09 -July -2014 as 10.1 164/rccm.201407-1198PP page 18 of 27 2012 inviting further comment on electronic nicotine delivery systems including electronic cigarettes (60). It concluded that the popularity of electronic nicotine delivery devices was growing rapidly, that health and safety concerns have not been resolved and that more research must be conducted, especially with regard to their safety of these devices and the marketing claims made by the rianufacturers. Additional concerns were that Electronic cigarettes resemble combustible cigarettes and could undermine the denormalization of tobacco use that is an important tenet of tobacco control. A guiding principle for implementation of the Framework Convention is to use education, communication, training, and public awareness "to change social, environmental and cultural norms and perceptions regarding the acceptability of the consumption of tobacco products, exposure to tobacco smoke ..." The producers of electronic cigarettes have spent large sums in advertising to portray "vaping" as a socially acceptable and desirable activity. A ban of electronic nicotine delivery devices could turn back this advertising movement, which aims to change the social norms to favor consumption of these "tobacco -like" products. If electronic nicotine delivery devices are regarded as imitation tobacco products and banned, then all electronic nicotine delivery devices would be covered, regardless of whether or not they contain nicotine or tobacco extracts. The Framework already has provisions, such as Article 5.2(ti), that requires parties to the treaty to "adopt and implement effective ... measures ... for preventing and reducing ... nicotine addiction ..." This 18 Copyright © 2014 by the American Thoracic Society Page 19 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1 164/rccm.20 1407- 1 1 98PP article could potentially mandate a ban on electronic nicotine delivery devices that contribute to maintaining addiction to nicotine. Furthermore, under Article 13.2, parties to the treaty have an obligation to undertake a comprehensive ban of all tobacco advertising, promotion, and sponsorship. Therefore, parties to the treaty may also consider whether the sale, advertising, and even the use of electronic cigarettes could be considered as promoting tobacco use, either directly or indirectly. Regardless of whether or not electronic nicotine delivery devices contain nicotine or tobacco extracts, they are used to mimic smoking, which could be considered as a (direct or indirect) promotion of tobacco use. Article 16.1(c) could also be relevant since it requires parties to prohibit "the manufacture and sale of ... any other objects in the form of tobacco products which appeal to minors." Additionally, the use of electronic nicotine delivery devices could be conceived as counter to Article 8 (Protection from exposure to tobacco smoke) that protects individuals in public places, because electronic cigarettes produce emissions that can be regarded as second- hand smoke. If electronic nicotine delivery devices are not banned, the strategy of the Framework could be to regulate them as both a tobacco and a medical product and close loopholes in their regulation. If electronic cigarettes are marketed with therapeutic or health claims, they should be regulated as medical products and be subject to the Framework's relevant regulations, most notably the requirement to provide data substantiating those claims in order to obtain market authorization. If the Framework parties decided to categorize and 19 Copyright C` 2014 by the American Thoracic Society AJRCCM Articles in P-ess. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP page 20 of 27 regulate electronic nicotine delivery devices as tobacco products, all provisions of the tobacco part of the Framework would apply. 20 Copyright C 2014 by the American Thoracic Society Page 21 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164/rccm.201407- 1198PP FIRS POSITIONS ON ELECTRONIC NICOTINE DELIVERY DEVICES The Forum of International Respiratory Societies (FIRS) has the following positions and concerns on electronic nicotine delivery devices: • There is concern that the use of electronic cigarettes is growing rapidly, especially among young people and women. Their acceptance may be attributed in part to the perception created by marketing and the popular press that they are safe. • The health risk of electronic cigarettes has not been adequately studied. • The addictive power of nicotine and its untoward effects should not be underestimated. • The potential benefits of electronic nicotine delivery devices, including harm reduction and enhancing smoking cessation, have not been adequately studied. • Potential benefits to an individual smoker should be weighed against harm to the population of increased social acceptability of smoking and use of nicotine. • Health and safety claims regarding electronic nicotine delivery devices should be subject to evidentiary review. • Adverse health effects for third parties exposed to the emissions of electronic cigarettes cannot be excluded. • Parties to WHO Framework Convention on Tobacco Control should consider whether allowing use of electronic cigarettes is consistent with the requirements of the treaty. • Electronic nicotine delivery devices should be restricted or banned, at least until more information about their safety is available. 21 Copyright - 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1164/rcem.201407- 1198PP page 22 of 27 In the absence of a ban, we recommend that devices that deliver nicotine be regulated as medicines. This includes the prohibition of their promotion for tobacco -use cessation and other health effects until there is strong evidence that establishes their benefits and lack of harm as is required by regulatory agencies for approval of other medicines. If electronic nicotine delivery devices are not regulated as medicines, they should be regulated as tobacco products. This includes: 1) a ban on all advertising, promotion and sponsorship; 2) prohibition of displays in retail stores; 3) prohibition of sale to minors; 4) regulation of internet sales; 5) taxation at rates similar to combustible cigarettes; 6) prohibition of sales and refills with flavors that will appeal to children; 7) requirement that packaging and labelling include a list of all ingredients and the quantity of nicotine; 8) placement of appropriate warning labels, the same as is required for tobacco products; and 9) prohibition of their use in public places, workplaces, and on public transportation. In the absence of a ban, manufacturers of electronic cigarettes should adhere to established consumer safety practices that list ingredients and produce consistent products with uniform concentrations arid defined maximum doses of nicotine. They must safeguard against inadvertent poisonings, which includes child - proofing containers and other protections. Research supported by sources other than the tobacco or electronic cigarette industry should be carried out i:o determine the impact of electronic nicotine delivery devices on health in a wide var ety of settings. The use and population effects of electronic nicotine delivery devices should be monitored. All information derived from this research should be conveyed to the public in a clear manner. 22 Copyright <; 2014 by the American Thoracic Society Page 23 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP SUMMARY Electronic cigarettes are nicotine delivery devices that have rapidly gained popularity because of marketing and the belief that they are safe and helpful for cessation of cigarette smoking. The health risks of these products, however, have not been adequately studied. Because nicotine is highly addictive, affects many bodily cells and functions, and is known to have many adverse effects, it is prudent to restrict usage of these products at least until their safety can be established. 091 Copyright CO 2014 by the American Thoracic Society AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rcem.201407-1198PP Page 24 of 27 REFERENCES 1. World Health Organization - Tobacco Free Initiative. Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS) - statement, July 2013 [Web Portal]. WHO, Geneva. [serial online] 2013 [cited 22 August 2013]. Available from: http: / /www.who.int /tobat :co/ communications /statements / eletronic cigarettes /en /index.ht nil 2. Adkison SE, O'Connor, R. J., Bansal- Travers, M., Hyland, A., Borland, R., Yong, H. H., Cummings, K. M., McNeill, A., Thrasher, F., Hammond, D., Fong, G. T. Electronic nicotine delivery systems: international tobacco control four - country survey. American journal of preventive medicine 2013; 44: 207 -215. 3. New York Times. Philip Morris ready to test new electronic cigarette device [Sourced from the Legacy Tobacco Documents Library University of California San Francisco]. [serial online] 1997 [cited 7 September 2013]. Available from: http: // legacy .library.ucsf.edu /tid /vrp10i00 4. United States Food and Drug Administration. Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products; Proposed Rule. 2014 [cited 2014 May 25, 2014]. Available from: littp://www.gpo.gov/fdsys/pkg/FR- 2014- 04- 25/pdf/2014- 09491.pdf. 5. Regan AK, Promoff, G., Dube, S. R., Arrazola, R, . Electronic nicotine delivery systems: adult use and awareness of the in the USA. Tobacco control 2013; 22: 19 -23. 6. King BA, Alam, S., Promoff, G., Arrazola, R., Dube, S. R. Awareness and ever -use of electronic cigarettes among u.s. Adults, 2010 -2011. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco 2013; 15: 1623 -1627. 7. Pearson JL, Richardson, A., Niaura, R. S., Vallone, D. M., Abrams, D. B. e- Cigarette awareness, use, and harm perceptions in LIS adults. Am J Public Health 2012; 102: 1758 -1766. 8. World Health Organization Regional Office for South East Asia. Global Adult Tobacco Survey: Indonesia Report 2011. [serial online] 2012 [cited 6 September 2013]. Available from: httP: / /www.searo.who.inl1entity /tobacco /data /gats Indonesia 2011.pdf 9. Medicines and Healthcare Products Regulatory Agency (MHRA). MHRA. Nicotine containing products.. 2013 April 27, 2014. Available from: http:// www. mhra. gov. uk/ Safetyinformation/ Generalsafetyinformationandadvice /P rod uct- specificinformationandadvice/Product- specificinformationandadvice% E2% 80% 93M% E2% 80 %93T /NicotineContainingProducts /inde x.htm. 10. US Centers for Disease Control and Prevention. Electronic Cigarette Use Among Middle and High School Students - United States, 2011 -2012. Morbidity and Mortality Weeky Report - September 6 2013. 11. International Union Against Tuberculosis and Lung Disease. Position statement on electronic cigarettes (ec) or electronic nicotine delivery systems (ENDS). 2013 ed. Paris, France: International Union Against Tuberculosis and Lung Disease,; 2013. 12. Scottish Directors of Public Health Group. E- Cigarettes and NHS Tobacco Policies - Position Statement By Scottish Directors of Public Health - Thursday 6th June 2013,. [serial online] 2013 [cited 22 August 2013]. Available from: http://tobacco.cleartheair.org.hk/wp- conte nt /uploads /2013 /06 /E -cig -N HS- Tobacco - Policy -State ment- 24 -5 -13. pdf 13. Campaign for Tobacco -Free Kids. Policy Statement Regarding E- Cigarettes - FDA and the States Must Regulate E- Cigarettes to Protect Public Health. [serial online] 2013 [cited 22 August 2013]. Available from: http: / /tobaccofreecampus.org/ sites /default /files / resources /TFK%20E %20cigarettes %20Polic y %20Statement %20FINAL %207- 17 -13. pdf 24 Copyright n 2014 by the American Thoracic Society x Page 25 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10. 1 164/rccm.201407-1198PP 14. Cancer Society of New Zealand. Cancer Society of New Zealand position statement on e- cigarettes [developed June 2011, due for review 2014]. [serial online] 2011 [cited 22 August 2013]. Available from: http://www.cancernz.orp,.nz/ assets /files /dots /position- statements /E- cigarette Position5tatement 1Aug2011.pdf 15. Bassett RA, Osterhoudt K, Brabazon T. Nicotine poisoning in an infant. The New England journal of medicine 2014; 370: 2249 -2250. 16. Vakkalanka JP, Hardison LS, Jr., Holstege CP. Epidemiological trends in electronic cigarette exposures reported to U.S. Poison Centers. Clinical toxicology 2014; 52: 542 -548. 17. Cobb NK, Byron, M. J., Abrams, D. B. Shields, P. G. Novel nicotine delivery systems and public health: the rise of the "e- cigarette ". Am J Public Health 2010; 100: 2340 -2342. 18. Flouris AD, Chorti, M. S., Poulianiti, K. P., Jamurtas, A. Z., Kostikas, K., Tzatzarakis, M. N., Wallace Hayes, A., Tsatsaki, A. M., Koutedakis, Y. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhalation toxicology 2013; 25: 91- 101. 19. Vardavas Cl, Anagnostopoulos, N., Kougias, M., Evangelopoulou, V., Connolly, G. N., Behrakis, P. K. Short -term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest 2012; 141: 1400 -1406. 20. Cheah NP, Chong, N. W., Tan, J., Morsed, F. A., Yee, S. K. Electronic nicotine delivery systems: regulatory and safety challenges: Singapore perspective. Tobacco control 2012. 21. Eissenberg T. Electronic nicotine delivery devices: ineffective nicotine delivery and craving suppression after acute administration. Tobacco control 2010; 19: 87 -88. 22. Bahl V, Lin, S., Xu, N., Davis, B., Wang, Y. H., Talbot, P. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reproductive toxicology 2012; 34: 529- 537. 23. Trtchounian A, Talbot, P. Electronic nicotine delivery systems: is there a need for regulation? Tobacco control 2011; 20: 47 -52. 24. Trtchounian A, Williams, M., Talbot, P. Conventional and electronic cigarettes (e- cigarettes) have different smoking characteristics. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco 2010; 12: 905 -912. 25. Drummond MB, Upson D. Electronic cigarettes. Potential harms and benefits. Annals of the American Thoracic Society 2014; 11: 236 -242. 26. Williams M, Villarreal, A., Bozhilov, K., Lin, S., Talbot, P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PloS one 2013; 8:e57987. 27. German Cancer Research Center - DKFZ (Ed.). Electronic Cigarettes - An Overview. DKFZ Heidelberg. [serial online] 2013 [cited 7 September 20131. Available from: htt : /www.dkfz.de /en /presse/ download /RS- Vol19 -E- Cigarettes- EN.pdf 28. Polosa R, Rodu B, Caponnetto P, Maglia M, Raciti C. A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm reduction journal 2013; 10: 19. 29. U. S. Department of Health and Human Services OotSG. The Health Consequences of Smoking - 50 Years of Progress: A Report of the Surgeon General, 2014 [serial online] 2014 [cited April 27, 2014]. Available from: http: / /www.surgeongeneraI.gov /library /reports /50- years -of- ro ress 30. Benowitz NL. Nicotine addiction. The New England journal of medicine 2010; 362: 2295 -2303. 31. Benowitz NL. Clinical pharmacology of nicotine: implications for understanding, preventing, and treating tobacco addiction. Clinical pharmacology and therapeutics 2008; 83: 531 -541. 32. Bruin JE, Gerstein HC, Holloway AC. Long -term consequences of fetal and neonatal nicotine exposure: a critical review. Toxicological sciences : an official journal of the Society of Toxicology 2010; 116: 364 -374. 33. Leone A, Landini L. Vascular pathology from smoking: look at the microcirculation! Current vascular pharmacology 2013; 11: 524 -530. 25 Copyright 10 2014 by the American Thoracic Society AJRCCM Articles in Piess. Published on 09 -July -2014 as 10.1164/rccm.201407- 1198PP page 26 of 27 34. Hanna ST. Nicotine effect on cardiovascular system and ion channels. Journal of cardiovascular pharmacology 2006; 47: 3,18 -358. 35. Gaemperli O, Liga R, Bhamra -Ariza P, Rimoldi 0. Nicotine addiction and coronary artery disease: impact of cessation interventions. Current pharmaceutical design 2010; 16: 2586 -2597. 36. Santanam N, Thornhill BA, Lau 1K, Crabtree CM, Cook CR, Brown KC, Dasgupta P. Nicotinic acetylcholine receptor signaling in atherogenesis. Atherosclerosis 2012; 225: 264 -273. 37. Li ZZ, Dai QY. Pathogenesis of abdominal aortic aneurysms: role of nicotine and nicotinic acetylcholine receptors. Mediators of inflammation 2012; 2012: 103120. 38. Hafstr6m 0, Milerad J, Sandbe -g KL, Sundell HW. Cardiorespiratory effects of nicotine exposure during development. Respiratory physiology & neurobiology 2005; 149: 325 -341. 39. Chu KM, Cho CH, Shin VY. Nicotine and gastrointestinal disorders: its role in ulceration and cancer development. Current pharmaceutical design 2013; 19: 5 -10. 40. Lee J, Cooke JP. Nicotine and pathological angiogenesis. Life sciences 2012; 91: 1058 -1064. 41. Wessels C, Winterer G. Nikotin and Gehirnentwicklung. Der Nervenarzt 2008; 79: 7 -8, 10 -12, 14- 16. 42. Raval AP. Nicotine addiction causes unique detrimental effects on women's brains. Journal of addictive diseases 2011; 30: 149 -158. 43. Kallala R, Barrow J, Graham SIVI, Kanakaris N, Giannoudis PV. The in vitro and in vivo effects of nicotine on bone, bone ce Is and fracture repair. Expert opinion on drug safety 2013; 12: 209 -233. 44. Demirhan 0, Demir C, Tunc E, nandiklioglu N, Sutcu E, Sadikoglu N, Ozcan B. The genotoxic effect of nicotine on chromosomes of human fetal cells: the first report described as an important study. Inhalation toxicology 2011; 23: 829 -834. 45. Caponnetto P, Campagna, D., Cibella, F., Morjaria, J. B., Caruso, M., Russo, C., Polosa, R. EffiCiency and Safety of an electronic cigAreTte (ECLAT) as Tobacco Cigarettes Substitute: A Prospective 12 -Month Randomized Control Design Study. PloS one 2013; 8: e66317. 46. Polosa R, Morjaria JB, Caponne!tto P, Campagna D, Russo C, Alamo A, Amaradio M, Fisichella A. Effectiveness and tolerabi ity of electronic cigarette in real -life: a 24 -month prospective observational study. Intern Emerg Med 2013. 47. Bullen C, Williman, J., Howe, C., Laugesen, M., McRobbie, H., Parag, V., Walker, N. Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet [Published Online September 7] [serial online] 2013 [cited 13 September 20131. Available from: http: // press .thelancet.com /ecigarettes.pdf 48. Popova L, Ling, P.M. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health 2013; 1.03: 923 -930. 49. McMillen R, Maduka, J., Winickoff, J. Use of emerging tobacco products in the United States. J Environ Public Health 2012; 2012: 989474. S0. Grana RA, Popova L, Ling PM. A Longitudinal Analysis of Electronic Cigarette Use and Smoking Cessation. JAMA internal medicine 2014. S1. Chapman S. Should electronic cigarettes be as freely available as tobacco cigarettes? No. Bmj 2013; 346: (3840. 52. Benowitz NL. Emerging nicotire delivery products. Implications for public health. Annals of the American Thoracic Society 2014; 11: 231 -235. 53. World Health Organization. MPower - Tobacco Free Initiave. 2013 December 2013 [cited 2014 April 27, 2014]. Available from: http: / /www.who.int /tobacco /mpower /en /. 54. Legacy Tobacco Documents Library. Legacy Tobacco Documents Library,. University of California San Francisco Library. 55. McCarthy M. Tobacco companies must admit deceit in massive new advertising campaign. Bmj 2014;348:g266. 56. European Parliment. Manufacture, presentation and sale of tobacco and related products. 2014 Febuary 26, 2014 [cited 2014 April 19, 2014]. Available from: FM Copyright f) 2014 by the American Thoracic Society Page 27 of 27 AJRCCM Articles in Press. Published on 09 -July -2014 as 10.1 164/rccm.201407- 1198PP (http: / /www.eu roparl.europa.eu /sides /getDoc.do ?pu bRef=-//EP/ /TEXT +TA +P7- TA -2014- 0160 +0 +DOC +XM L +VO //E N. 57. Torjesen I. E- cigarettes are to be regulated as medicines from 2016. Bmj 2013; 346: f3859. 58. Osman N. Imported E- Cigarettes Banned and Dangerous, Indonesia Drug Agency Claims [news article] in Jakarta Globe The Jakarta Globe [serial online] 2010 [cited 7 September 2013]. Available from: http://www.the*akartaglobe.com/ archive /imported -e- cigarettes - banned- and- dangerous- indonesia -drug agency claims/ 59. Republic of the Philippines Food and Drug Administration. Secondary exposure to E- cigarette exposure might be harmful - FDA Advisory 2013 -015. [serial online] 2013 [cited 7 September 2013]. Available from: http: / /www.fda.gov.ph/ attachments /article /80233/FA2013- 015.pdf 60. World Health Organization - FCTC Secretariat. Electronic nicotine delivery systems, including electronic cigarettes FCTC /COP /5/13 - Report by the Convention Secretariat 18 June 2012. [serial online] 2012 [cited 7 September 2013]. Available from: http: // apps .who.int /gb /fctc /PDF /cops /FCTC COPS 13- en.pdf 61. United States Food and Drug Administration [FDA]. Electronic Cigarettes (e- Cigarettes) - web portal - Public Health Focus. [serial online] 2013 [cited 22 August 2013]. Available from: http:// www. fda. gov/ newsevents /publichealthfocus /ucm 172906.htm 62. World Health Organization. WHO Framework Convention on Tobacco Control. [serial online] 2013 2003 [cited April 19, 2014]. Available from: http: / /www.who.int /fctc /text download /en/ 27 Copyright © 2014 by the American Thoracic Society A D X VL> ' 7 Cedar St., Suite A N (go" Summit, NJ 07901 x Phone: 908- 273 -9368 Fax: GASP S Email: infoC@njgasp.org www.njgasp.org FFaE> Karen Blumenfeld, Director Tobacco Control Policy and Legal Resource Center Kater;.Biurrnentelu,u verizon.neL August 25, 2014 ELECTRONIC SMOKING DEVICES Introduction The electronic smoking device industry has evolved and now offers more products than electronic cigarettes, like hookah pens and electronic cigars. Some industry trade groups refer to these products as Personal Electronic Vaporizing Units (PEVUs). Throughout this paper, the term "e- cigarette" is used broadly to include all types of electronic smoking devices. Global Advisors on Smokefree Policy' ( "GASP ") has many health concerns regarding e- cigarette use and exposure, which are documented in this paper. The U.S. Food & Drug Administration (FDA), U.S. Senator Frank Lautenberg, the World Health Organization, and national advocacy organizations also voice their concerns about e- cigarettes. Local, county, state and international jurisdictions are restricting or banning the sale or use of e- cigarette products. I. Laws and Policies New Jersey restricts e- cigarette sales and use New Jersey was the first state in the nation to ban the use of e- cigarettes in public places and workplaces, effective March 13, 2010. On January 11, 2010, Governor Corzine signed into law A4227/A4228/S3053/S3054, banning e- cigarette use in public places and workplaces (amended 2006 NJ Smokefree Air Act), and banning e- cigarette sales to people 18 years and younger. The New Jersey Senate and Assembly both voted unanimously in favor of the law. See http: / /nocciaso.org /sfaa 2010 w- eciaspdf and njlea. state .ni.us /2008/Bills/A4500/4227 U l.odf. On August 7, 2013, the New Jersey Department of Health's Office on Local Public Health, in cooperation with the Department's Office on Tobacco Control, issued as a reminder an Administrative Advisory and two handouts that the use of electronic smoking devices is prohibited in indoor public places and work places. http: / /www.neaaso.orci /NJ State E -cias Advisory 2013.pdf http: / /www.nigasr).ora /NJ Smokefree Air Act and Breathe Easy flyer.odf The impetus for the New Jersey state law came from a local Board of Health and County Board of Chosen Freeholders. In October 2009, New Jersey's Bergen County Board of County Freeholders passed a resolution banning e- cigarette use in county buildings, at county parks and recreational areas. On November 23, Paramus' Board of Health passed an ordinance restricting e- cigarette use in public places and workplaces, taking effect on December 1, 2009. Global Advisors on Smokefree Policy (GASP) is a 40 -year old nonprofit resource center, dedicated to promoting smokefree air and tobacco -free lives. GASP is funded by the New Jersey State Department of Health, private foundations and donations. LIM Other state -wide laws amend smoke -free air act to include e- cigarettes Effective December 6, 2012, North Dakota amended chapter 23 -12 to expand the smokefree air act to more public places and workplaces, and included electronic smoking devices in the ban. It was by voter referendum on Measure 4 (2/3 voted in favor), and includes bingo and gaming facilities as defined by chapter 12.1- 28 -01. Smoking is defined as "inhaling, exhaling, burning, or carrying any lighted or heated cigar, cigarette, or pipe, or any other lighted or heated tobacco or plant product intended for inhalation, in any manner or in any form. Smoking also includes the use of an e- cigarette which creates a vapor, in any manner or any form, or the use of any oral smoking device for the purpose of circumventing the prohibition of smoking in this Act." Measure 4 is at Irit _. /yl�ir),sos. rid.a ov/ pdfs/`­Portals /BallotLai-iguaaeMeasure4- Smoking Nov6.2012.pcli. Chapter 23 -12 is at htto: Lvyww.legis.nd.gov /cencode /t23c]2.odf ?20131115142855. Definition of gaming facilities is at 1)1!pjLwwwLlegis.nd.gov/cencodelt]2-ic28.r)df?20131115144000. Effective March 12, 2012, Utah signed HB245 into law which amended the Utah Indoor Clean Air Act (Rule R392- 510.2(5)) adding e- cigarettes to the definition as a tobacco product. htip: / /Ie.utah.gov /- 2012 /htmdoc /hbillhtm /hb0245s03.htm Other state, county, and local laws restricting e- cigarette sales and use in the U.S. (listed alphabetically, by state) • Alabama: Effective August 1, 2013 bans the sale and use of e- cigarettes to minors under age 19. http: / /Iegiscan.com /AL /bill /H 3286/2013 • Arizona: Effective September 13, 2013 bans the sale of e- cigarettes to minors under the age of 18. htto: / /www.kvoo.com/ news / ,iew- tobacco - rule -in- arizona- bans- sale- of- e- cigs -to- minors/ #. • Arkansas: Effective April 11, 2013 bans the sale and use of e- cigarettes to minors. htio : / /www.stampoutsmokinci.com /wp- content /uploads /2013/05 /ACT - 1099 -e- cigarette- law.r)df • California: On July 29, 2010, the California Attorney General enters into a Stipulated Consent Agreement with NJOY, an e- cigarette manufacturer and retailer. The Agreement settles the lawsuit filed by the Attorney General, making it unlawful for NJOY to sell e- cigarettes to a minor, along with other restrictions on marketing and sales of e- cigarettes. http: / /oag.ca.gov/ news / press - releases /browri- anriounces- electronic - ciaarette -_ makers - agreement - stop - deceptive- marketing • California: On September 27, 2011, Concord City enacts an ordinance requiring a 17- block downtown business district be 100% smokefree, including banning the use of e- cigarettes. http: / /www.ci. concord. ca. us /r)df /citygov /agendas /council /201 1 /0927 /4A.odf • California: Effective December 4, 2013, Los Angeles passed a law classifying electronic cigarettes as tobacco products, limiting sale locations and requiring a license to sell. http: / /www.njgasp.org /LATimes ecigs tobacco 12- 4- 13.odf • California: Effective February 9, 2013, Petaluma bans smoking of e- cigarettes in public places and workplaces. htto://www.petaluma360.coiii/orticle/20130108/community/i 30109651 • Colorado: Effective July 1, 2011, bans the sale of e- cigarettes to minors. htto: / /www.leg.state.co.us /c ics /clics201 1 a/c sl. nsf/ fsbillcont3 /78CCDD6C6E59B37 1 872578080080 1 3 AE ?open &fi1e =1016 enr.odf • Georgia: Effective January 2011, Savannah amended their 2010 smokefree air act to include the use of e- cigarettes in public places and workplaces as well as outdoor locations (10 foot buffer zone, outdoor service lines, outdoor dining, playgrounds, etc.) httr): / /www.nigasr).ora /Savannah SFAO 2010.pdf • Georgia: Effective April 25, 2012, Chatham County includes e- cigarettes in their smokefree air law for all public places and workplaces. lii wV v <,A c,�Iiiliy,U�alll U11, ( d:pj ,.20County %2OSnlokefree.odi • Hawaii: Effective May 2, 2013 bans sale of e- cigarettes to minors under 18 years of age and requires tobacco products to be sold face -to -face, not through the internet. httr)://www.caoitol.hawaii.gov/measure indiv asox?billtvpe= HB &billnumber= 672 &Year =2013 • Idaho: As of July 1, 2012 bans the sale of e- cigarettes to minors and bans possession of e- cigarettes by minors. httQ: / /Iegislature.idaho.gov /legislation /2012 /HO405.rDdf • Illinois: Effective January 1, 2014, bans the sale of e- cigarettes and alternative nicotine products to people under the age of 18. The law passed August 2013. httQ:/ /www nacsonlirie con)/ News / Daily/ Pages /ND0819132.aspx #.UirinyRb3A3Z • Illinois: Effective October 28, 2013, Evanston amended its local "Clean Air Act ": o bans the use of e- cigarettes in public places and workplaces • Requires a $500 /year license to sell at retail tobacco or liquid nicotine products. • Can't sell or give tobacco or liquid nicotine products 150 feet from a K -12 school; $500 1st offense, $1000 second offense, license revocation for more offenses. • Minors cannot be sold or purchase tobacco or liquid nicotine products. • Minors cannot possess tobacco or liquid nicotine products in public places. • The sale or giving of bidi cigarettes is prohibited to any person, regardless of age. • Minors cannot sell tobacco products for a retail licensee. • Tobacco and liquid nicotine products are banned from self - service display racks, for sale, display or giving away. • Tobacco and liquid nicotine products are banned for sale via vending machines except in non - public places, and are banned from free distribution by a licensee or person in the business at any right of way, park, playground, other city owned property, or any school district, park district or public library httr): / /www.nigasp.org /Evanston IL ecia ban 10- 28- 13.odf • Illinois: Effective February 14, 2014, Chicago passed an ordinance to ban e- cigarettes in indoor public places and workplaces and to restrict how and where e- cigarettes can be sold. htt[p://www.niQasr).org/ChicacioTriburie ECia Ban 1 -15 -14 pdf • Indiana: Effective July 1, 2013 bans the sale and use of e- cigarettes to people under age 18 and puts restrictions on the display and vending of e- cigarettes. httrp://www.in.gov/leqislative/bills/2013/­`HB/HB I 225.2.html • Indiana: Effective December 2012, Indianapolis amended their smokefree air law to include electronic smoking devices. htto://www.indy.Qov/eGov/Council/Proposals/­Documents/2012/PROP I -136 pdf • Kansas: As of July 1, 2012 bans the sale of e- cigarettes to minors. htto://Ieqislature.idaho.gov/ieqislation/2012/­HO405.pdf a • Kentucky: Effective June 2011, the city of Bardstown bans the use of e- cigarettes in public places and workplaces; signed into law on March 9, 2010. http: / /www.cityofbardstown.orq /odfs- ordinances /Chapter 123.pdf • Kentucky: Effective September 19, 2011, Bullitt County Board of Health bans smoking in public places and workplaces, including the use of e- cigarettes (The original law that passed 3/22/10 was appealed but the court sided with the Board of Health). http:// www. bullittcountyhealihdept .com /BOH %2ORegulation %2010- O1.pdf • Kentucky: Effective June 2011 the city of Glasgow bans the use of e- cigarettes in public places and workplaces; signed into law in March 2010. htto://blogs.theheart.ora/melissa- wal ton - shirley -blog/ 2010 /3 /26 /Qlasgow- kentuckv -goes- smoke - free - war - and - peace - part -1. See also httr)://www.ctpost.cDm/ news /article/ Madison - County- adds -e- cigarettes -to- smoking -ban- 1326985.php • Kentucky: Effective June 6, 2011 Madison County Board of Health amends its smoking ban ordinance to include a ban on using e- cigarettes in public places and workplaces. htf p:/ lwww .madisoncountyh�Dalthdept.org /Documents /Community /REVISED MCHR 700.pdf • Maryland: Effective October 1, 2012 bill HB1272 bans the sale of e- cigarettes to minors under 18. http:// mgaleg. marvland .gov,lwebmga /frmMain.aspx? tab= subject3 &vs= 2012rs %2fbillfile %2fhb 1272. htm • Massachusetts: Effective January 1, 2014, Ashland bans the sale of any tobacco and nicotine delivery product to persons under age 21 (minor defined as under 21). The comprehensive policy also requires retail establishments to obtain a permit to sell tobacco or nicotine delivery products (not only FDA approved tobacco cessation products), bans issuing a permit if it is for an establishment located within 500 feet of a school, and will only issue 8 permits total at one time. Ashland also bans self- service and vending machines of tobccco products and nicotine delivery products, requires all humidors in stores to be locked, requires cigars only be sold in 4 packs or more unless each cigar is $2.50 or more, bans all non - residential RYO machines, and bans free distribution of sample tobacco products or nicotine delivery products. hl�_( /njaasp.org /Ashland MA ageofsale to 21 1- 1- 14.pdf Massachusetts: Effective December 2011, Boston Public Health Commission votes to prohibit the use of e- cigarettes in workplaces, and prohibit the sale or distribution of unregulated nicotine delivery products to minors. http: / /www.blDhc.ora /whatwedo /tobacco -free- living /Documents /Amended Clean Air Works Workplace E Cigarette Restrictions Regulation.pdf #search = clean %20air %20works. Effective December 30, 2013, the electronic smoking device ban was extended to include parks, squares, cemeteries and other spaces run by the Parks and Recreation Department. http : / /www.nigasio.org /BostonGlobe ParkSmokingBan with ecigs 12- 31- 13.pdf • Massachusetts: Effective January 2014, the Canton Board of Health bans the sale of all nicotine products, includirg e- cigarettes, to people under the age of 21. The regulation passed on August 12, 201 htto: / /www.n'aaso.or /q PatriotLedger Canton ecig sales aaeto2l 8- 13- 13.pdf • Massachusetts: Effective November 8, 2012, Great Barrington, updates its Environmental Tobacco Smoke Regulations to include banning e- cigarettes where smoking is already prohibited. http: / /www.townofgb_orQ /Pages /GBarringtonMA Health /TOBACCO REGULATIONS 2012pdf • Massachusetts: As of February 2, 2014, Lowell Board of Health bans the smoking of electronic cigarettes in public places and bans the sale to minors. http : / /www.njgasp.org /LoweliSur) ecig minor ban 2- 2- 14.pdf • Massachusetts: Effective July 1, 2012, North Adams Board of Health (Lee, Lenox, Stockbridge) amends its local tobacco regulations to include e- cigarettes. The regulation restricts smoking in public places, sales of nicotine products in pharmacies, and restricts their use by /sales to minors. htto://www.iberkshires.com/story/41141 /Tri -Town- Health- Board - Bans - Tobacco - Sales- In- Pharmacies.html Massachusetts: Effective July 13, 2010, North Attleboro Board of Health (1) bans the use of nicotine delivery products in workplaces and public places covered by the state law, requires signage; (2) requires nicotine delivery products (e.g. e- cigarettes) be sold face - to -face, an only at a non - mobile retail establishment issued an annual permit by the local Board of Health; (3) bans the sale to minors, requires signage; and (4) bans free distribution and sampling. htto: // north- attleboro .ma.us /boh /PDF /Reaulations/ Nicotine% 20Delivery %20Product %20and %20E - Cigarette %20Regulation.gdf • Massachusetts: Effective September 1, 2012 the Saugus Board of Health voted unanimously on June 5 to ban the sale of e- cigarettes to minors and their use in a public places. htto:// www. wickedlocal. com /saugus /news /x2067836337/Saugus- Board- of- Health- res tricis- tobacco - sales# axzz2K3obfObL Massachusetts: Effective September 1, 2010 the Somerset Board of Health (1) bans the use of nicotine delivery products in workplaces and public places covered by the state law, requires signage; (2) requires nicotine delivery products (e.g. e- cigarettes) be sold face -to -face (not using self - service displays or vending machines), an only at a non - mobile retail establishment issued an annual permit by the local Board of Health; (3) bans the sale to minors, requires signage; and (4) bans free distribution and sampling. Up to $300 fine, and suspension of nicotine delivery products permit issued by the local Board of Health. Fines range from $100 $300 and 30 -day suspension of any and all Board of Health- issued permit. I ii Massachusetts: Effective October 29, 2009 the South Hadley Board of Health (1) bans the use of nicotine delivery products in workplaces and public places covered by the state law, requires signage; (2) requires nicotine delivery products (e.g. e- cigarettes) be sold face -to -face, an only at a non - mobile retail establishment issued an annual permit by the local Board of Health; (3) bans the sale to minors, requires signage; and (4) bans free distribution and sampling. http: / /www.southliadley.org /Pa(:Ies /Souti)HadleyMA Heal fh /forms /enicaopreas Minnesota: Effective August 1, 2010 bans the sale of e- cigarettes to minors, banning self - service displays of tobacco products and e- cigarettes except in adult -only facilities, and allowing for municipalities to license and regulate retail sales of e- cigarettes and tobacco products. http:// oublichealthlawcenter .ora:content:oassaae- tobacco- modernization - and - compliance -act- 2010 httos:/ /www. revisor.mn.gov /laws / ?id= 305 &year =2010 &type =0 htto: / /www.niaasp.org /Minnesota PR Tob Mod Compi Act- 2010.odf • Minnesota: Effective September 13, 2013, Duluth prohibits smoking e- cigarettes in places covered by the Minnesota Clean Indoor Air Act. The Minnesota Department of Health supported Duluth's ordinance. htto: // www. startribune.com /local/223235121.html CM • Mississippi: Effective July 1, 2013 bans e- cigarette sales to people under age 18. httr): / /billstatus.1s.state.ms.us /documents /2013 /odf /HB /0600 - 0699 /`HBO6131N.pdf • New Hampshire: Effective July 31, 2010 bans e- cigarette sales to minors. htto: / /IeQiscon.com /NH /bill /HB 1541/2010 New Jersey: Effective March 13, 2010, New Jersey is the first state in the nation to ban the use of e- cigarettes in public places and workplaces and ban the sale to minors. On January 11, 2010 New Jersey Governor Corzine signed into the law banning the use of e- cigarettes in workplaces aid public places, and banning the sale of e- cigarettes to persons 18 years and younger. The law amended the 2006 NJ Smokefree Air Act. http: / /www.n'leg. state .nj.us /2008/Bills/A4500/4227 U l .PDF • New Jersey: Effective November 23, 2009: Paramus Board of Health bans the use of e- cigarettes in public places and work places effective December 1, 2009. httg: / /www.nj aq sp. org/ Electrz)nic% 20Cicaarettes %20Paramus %200rdinance °102012- 2009.pdf • New Jersey: Effective October 7, 2009 Bergen County Board of Chosen Freeholders prohibits the use of e- cigarettes at all county parks where children are present, and inside county buildings and county vehicles. http: / /www.ngaaso.org /Bergen ecigs resolution.odf • New Mexico: Effective February 13, 2014. Santa Fe outlaws the sale of electronic cigarettes to minors and prohibits their use in bars, restaurants and other public spaces covered under the city's existing smoke -free ordinance. http : / /www.santafenewmi�xican.com /news /health and science /council - puts- strict- limits- on- e- cigarettes /article 38fb2bc6- f246- 5bd9- b02a- 36a63f45a903.html • New York State: Effective January 1, 2013 prohibits electronic smoking within 100 feet of the entrances or exits of any public or private schools and bans the sale of e- cigarettes to minors. Governor Cuomo signed the bill in September 2012; bill sponsor Assemblywoman Linda Rosenthal. http: /1newyo. rk. cbslocal,com(2012109[Ooy_Cuomo- signs- new - electronic - cigarette- restrictions into -law • New York City: Effective December 30, 2013 Mayor Bloomberg signed the law passed by City Council to include electronic smoking devices with its current smokefree ordinance of other tobacco products. This means that e- cigarettes cannot be smoked in indoor public places and workplaces or in city park and recreational areas. htto: / /www.nigasp.org /CBS NYC ban ecigs 12- 19- 13.pdf • New York City: Effective November 19, 2013 Mayor Bloomberg signed into law a bill that bans the sale of electronic: smoking devices to persons under age 21. NYC Councilman James Gennaro sponsored the bill. It takes effect in 180 days from the bill signing. httr-)://www.n'aasr-).gLgLNLewsday Bloomberg signs ageofsale 21 11- 19- 13.pdf • New York: Effective February 14, 2012, Cattaraugus County bans e- cigarette sales to minors and the use of herbal and e- cigarettes in public places and workplaces. • New York: Effective November 1, 2009, Suffolk County bans e- cigarette sales to persons under 19 and the use of e cigarettes in public places and workplaces. htto:// Iegis. suffo[kcountvny.gov /Resos2009 /i 1347- 09.odf • Oklahoma: Effective January 1, 2014 use of electronic cigarettes will be banned on all state -owned and state - leased properties http: / /www.nigaso.org /NewsOK OKECigBan 12- 13.ndf North Carolina: Effective December 1, 2013 bans e- cigarette sales to minors under age 18. http: / /www.ncga.state.nc.us/ Sessions / 2013 /Bills /House /PDF /H864v0.pdf Oregon: The first state to go to court to ban the sale of e- cigarettes in the state using the argument that the companies are misrepresenting the safety of their products by marketing them as a safe alternative to traditional tobacco products. On August 9, 2010, the Attorney General announces agreement with Florida -based Smoking Everywhere, Inc. and in July 2009, two settlements were reached: one prevented two national travel store chains from selling "electronic cigarettes ", and the other prevents Sottera, Inc. (distributor of NJOY) to do business in the state. htto: / /www.doi.state.or.us /releases /pages /20I 0 /reIO809 I O.aspx • Philadelphia Pennsylvania: On March 27, 2014 City Council adopted bans e- cigarette sales to minors under age 18 and added electronic cigarettes to existing tobacco use laws. http : / /www.nigasp.org /philadelphia- has - adopted -an- indoor - ban -on- electronic - cigarettes/ • South Carolina: Effective June 7, 2013 bans e- cigarette sales to minors under age 18. http : / /www.scstatehouse.gov /sessl20 2013 - 2014 /prever /3538 20130523.htm • Tennessee: Effective July 1, 2011, state code 39 -17 -1504 was amended to include e- cigarettes, making the sale or distribution of them illegal to minors under 18. http: / /www.capitol.tn.clov /Bills/ 107 /Bill /SB091 O.pdf • Texas: Effective 2014, San Marcos is including e- cigarettes with its smoking ban, which is effective January 1 for municipal facilities, city parks and athletic facilities and effective June 1 for businesses, restaurants and bars. tit�.1ww sanrnarcostx,gov n,odu ees /showdocumenLasux ?docunienticl -9647 htto: / /www.myfoxaustin.com/ story/ 24339469 /san- marcos -to- ban - smoking -e- cigarettes -in -2014 • Texas: Effective February 10, 2014, Lewisville bans e- cigarette sales to minors. litto: / /www.cityoflewisville. com /index.asox?page= 33&recordid =513 • Vermont: Effective July 1, 2013 bans e- cigarette sales to minors under age 18. http: / /www. '14.PDF • Washington: Effective July 28, 2013 bans the sale to minors under the age of 18. tittp: / /apps.lea.wa.gov /documents /bilidocs /2013- 14 /Pdf /Bills /Session %20Laws /House/ 1937.SL.pdf • Washington: Effective June 23, 2011, Clark County bans the sale of e- cigarette to minors. htt0: / /www.oregonlive .com /clark- county /index.ssf /2011 /06 /clark county bans sale of e- cigarettes to minors.html • Washington: Effective December 16, 2010 King County Board of Health bans the use of e- cigarettes in public places and work places, restricts the sales of e- cigarettes or any other unapproved nicotine delivery devices only to people 18 and older, and prohibits free or highly discounted electronic smoking devices or unapproved nicotine delivery products. http:// www .kingcountv.Qov /healthservices /health /BOH /regulations.asox • Washington: Effective March 31, 2011 Spokane County and City of Spokane banned the sale of e- cigarettes to minors. htto: / /www.kxiy.com/ news /City - County -Roll- Out - Minor - Ban -On -E- Cigarettes / -/ 101270/682924/ - /wlqws4/-/index.html 14 Washington: Effective June 2, 2011, Tacoma - Pierce County Health Department (1) bans the use of electronic smoking devices in public places where minors are permitted, exempt places :)f employment that are not public places and in retail outlets that exclusively sell or promote electronic smoking devices; and (2) bans free sampling or at nominal cost unless at an e- cigarette retail outlet; and (3) bans e- cigarette sales to minors. htto : / /www.tochd.orci/news.r)hp ?nid =647 htto: / /tpchd.org/files /library /22094f84d3bI40cb.odf • West Virginia: Effective June 23, 2011, Clark County bans the sale of e- cigarettes to anyone under 18 years of age. htto: / /www.oreciorilive.com /(,lark- county /index.ssf /201 1 /06 /clark county bans sale of e- cigarettes to minors.html Wisconsin: Effective April 20, 2012 prohibits the sale of e- cigarettes to people under age 18. htto: / /docs.leais.wisconsi -i.aov /statutes /statutes /134/66 • Wyoming: Effective March 13, 2013 bans the sale of e- cigarettes to people underage 18. http: / /Ieaisweb.state.wy.�js /2013 /Summaries /SF0103.htm Review a list of other U.S. municipalities and counties that restrict the use of electronic smoking devices, and some states that ban its use in State or educational facilities, at httg11www.no. sr �' ;te:.or�i� %`1t /t�.iu�lu� ✓�.pdi. Other restrictive policies in the U.S. (listed by most recently enacted): • July 1, 2013, Minnesota taxes e- cigarettes at a rate of 95% of the wholesale cost. htt[D: // www. csonet .com /catE�Qory- nianagement- news- data / tobacco - news- data /articles /vear- end- review- tobacco -le isq lation • March 15, 2013, U.S. Air Force changes its policy "Tobacco Use in the Military" (Air Force Instruction 40 -102) to include e- cigarettes and smokeless tobacco products which was adopted in 2010. lj. ltp.,Uwww.aerofechnews.r:om /nellisafb /2013/03/ 15 /air - force - aims -to- curtail_ electronic - cigarette -use/ In August 2010, the Air Force surgeon general, Lt. Gen. (Dr.) Charles B. Green, issued a memo alerting all Airmen about safety concerns regarding electronic cigarettes. The memo states that due to the nature, appearance and safety concerns of electronic cigarettes, they are considered to be in the same category as tobacco products, the use of which is governed by Air Force Instruction 40 -102, Tobacco Use in the Air Force. This new product will be included in the upcoming revision of AFI 40 -102 due out this fall. http: / /www.af.mil /news /story orint.aso ?id= 123218666 • December 2011, the New York Liquor Authority made a Declaratory Ruling that beer wholesalers who have a C license cannot sell e- cigarettes. https: / /www.sla.ny.gov /system /files /201 1- 03687- Saleofelectronic cigarettes. odf February 2011: The U.S. Department of Transportation (DOT) communicated in writing to New Jersey Senator Frank Lautenberg that the use of smokeless e- cigarettes on airplanes is prohibited. The DOT plans to issue an official ban in the spring of 2011. According to the Associated Press, Transportation Secretary Ray LaHood said the DOT has been informing airlines and the public that it interprets smoking regulations to include e- cigarettes. htto: / /www.n gaso.or.Q/DOT Policy on ecigs feb 2011 Itr to lautenbera.pdf Examples of enforcing the no e- cigarette use policy in- flight: o In July 2011, a passenger refused to extinguish his e- cigarette in- flight from Los Angeles to Salt Lake City on Southwest Airlines, and upon disembarking, the FBI charged him with interference with the flight crew. http: / /connect2utati.com /searc[)- fulltext ?nxd id= 156217 o January 24, 2011 an Allegiant Airlines flight was diverted when a passenger refused to stop using their e- cigarette in- flight. The passenger argued with the flight attendant, and the pilots diverted the plane. http://www.wvec.com/ home / Electronic- cigarette - leads- touriexr)ected- landing- in- Norfolk- 1 14504289.htm1 Senator Lautenberg wrote the 1987 law that banned smoking on airplanes; he asked the DOT to clarify the rule. In 2010, GASP requested Senator Lautenberg's office to look into clarifying the 1987 law banning smoking on airlines, to have it apply to electronic smoking devices as well. htt[Y.[ /www _ sfaate.com /cQi- 1 , � , .: , ; On January 24, 2011 an Allegiant Airlines flight was diverted when a passenger refused to stop using their e- cigarette in- flight. The passenger argued with the flight attendant, and the pilots diverted the plane. http://www.wvec.com/ home / Electronic - cigarette- leads- to- unexoected- landina -in- Norfolk- 114504289.html • September 30, 2010, San Francisco Airport Commission bans the use of e- cigarettes at the airport where smoking is banned. http : / /www.njgasp.ora /SaiiFraticisco AirportCommPolicy9.30.10.pdf August 2010, U.S. Navy announces that smoking will no longer be permitted below decks on its submarines, effective December 31, 2010. The policy includes e -cigs where are not approved by the FDA. The policy was initiated to protect the health of nonsmoking sailors. The Navy offers smoking cessation programs and nicotine replacement therapy will be widely available on the submarines. ivy news 4- 8- 2010.pdf • August 2010: Central Michigan University banned the use of e- cigarettes in all buildings and residence halls, and within a 25 feet perimeter of all buildings. htto:/ /www cni -life com /2010/08/ 19 /electronic- cigarettes- banned -in- campus- buildings- residence- halls October 14, 2009 Amazon.com prohibits sale of electronic tobacco products on their website, and Paypal cancels e- cigarette accounts. Onlineprnews.com reported on October 14, 2009, that internet retailer Amazon.com noticed its resellers that e- cigarettes and other e- tobacco products are "inappropriate for Amazon.com" and that Amazon.com is prohibiting the sale of such products. Onlineprnews.com also reported that Paypal cancelled its electronic cigarette accounts. http: / /www . njclasp.orq /OLPRMedia amazon ecigs removed 10 -19 09.pdf Restrictive international policies (by most recently enacted): December, 2013, Switzerland bans the use of e- cigarettes in public transport. The country also bons the sale of e- cigarettes but allows them to be imported. htfo: / /www.nigasr).org/Gooale Switzerland e -cia ban 11- 12 -11ndf • August 2013, UK Rail announces a complete ban on passengers using e- cigarettes anywhere inside stations. May 2013, First Capital Connect, a commuter train in the London metro area banned the use of e- cigarettes on its trains. http:/ /www.njgasp.org /IndependentCoUK train ecic�ban 8- 12- 13.pdf httip://www.n'ciaso.ora/UK Hunts Post E -cia ban fcc 5- 30- 11odf 14 • July 10, 2013, European Pairliament's Environment and Health Committee voted to back the European Commission's proposed tobacco restrictions. One was to regulate e- cigarettes as medicinal products if they contain 4 mg or more of nicotine. htto: / /www.nigaso.ora /EU E -tags as medicine 7- 17- 13.pdf • June 21, 2013, the European Union agreed on a directive to make tobacco products less appealing and limit all nicotine- containing products (including vapor products) with a nicotine level equal to or exceeding 1 mg per unit, or products with a nicotine concentration equal to or exceeding 2 mg per ml. � i_ �t I l At 1 1483.et 13.pdf June 2013, United Kingdom decides electronic cigarettes will be regulated as medicine by the Medicines and Healthcare products Regulatory Agency. Beginning 2016, e- cigarette manufacturers will have to prove the quality of their products and demonstrate they deliver the correct amount of nicotine to obtain a license to sell their products in the UK. http: / /www.n'aaso.ora /Reuters UK ecias regulated 6- 12- 13.odf • May 2011, Argentina passE�s resolution 3226/2011 to ban the importation, distribution, commercialization and advertising of e- cigarettes and paraphernalia related to them. htto : / /www.niciasp.orraa \Argentira bans e -cias YahooNews 5- 9- 2011.odf July 2010, Singapore bans e- cigarette importation, distribution and sales under Section 16 (1) of the Tobacco (Control of Advertisements and Sale) Act, enforced by the Health Sciences Authority (HSA). Prohibits the importation, distribution, sale or offer for sale of any confectionery or other food product or any toy or other article designed to resemble a tobacco product or packaging which is designed to resemble the packaging commonly associated with tobacco products. Fine is of up to $5, 000 upon conviction. www.niaasp.or /Singapore ban 7- 19- 10.pdf • January 2010, Malta bans cigarette use in public places where smoking is banned and bans sale to minors. t) ltrD : /larchive.rnaltatoday.cotn.mt /2010 /01 /]Q /tl4.lilt.i) • August 2009, Brazil bans the sale, importation and advertisement of electronic cigarettes. The Brazil's health and son tation federal agency, Anvisa, found the current health safety assessments about e- cigarettes not to be yet satisfactory to make the product eligible to be approved for commercialization. http:// www. estadao. com.br /noticias /vidae,anvisa- proibe- comercializacao- do- c :igarro- eletronico,427373,0.htm • July 2009: Israeli Health Ministry bans e- cigarette sales and importation. htto: // www. israelnotionainev ,ts.com /SendMail.asr)x ?print = print &tvpe =0 &item = 132629 June 2009: Panama bans the importation, distribution and sale of e- cigarettes. Ministry of Health cites FDA findings cs reason for their ban. tiUp:// mensual. prensa.com /rnens_u_al/`contenido /2009/ 10 /22 /hov /panorama/ 1969677.aso March 27, 2009, Canada bans sale of e- cigarettes that contain nicotine. Health Canada called for the immediate cessation of imports, sales, and advertising of electronic smoking products contain ng nicotine, and advised Canadians not to purchase or use any electronic smoking products. Under the Canadian Food and Drugs Act, Food and Drugs, electronic smoking products containing nicotine require market authorization before they can be imported, marketed, or sold. As of March 27, 2009, no electronic smoking product has been authorized for sale by Health Canada. htto://www.hc- sc.Qc.ca/dhr)-rnPs/rDrodph ar ma/applic-dernande/pol/notice avis e- cig- ena.php 10 • March 2009, Hong Kong bans the use and sale of electronic cigarettes, unless registered as a pharmaceutical product with the government. htto:// www.tco.aov.hk /textonly /enalish /infostation /infostation 04032009.html and httip://www.thestandard.com.hk/news detail asp?oo cat =30 &art id= 79120 &sid = 22983216 &con tvoe =3 • January 2009, Jordan's Ministry of Health banned the import of the electronic cigarettes, citing World Health Organization's health concerns. htto://www.iordantimes.com/?news=13857 • January 2009, Victoria (Australia) bans e- cigarette use, sales and advertising. Australian law classifies nicotine as a poison (only exemption is for cigarettes and for cessation products). E- cigarettes have not been evaluated for safety and efficacy: According to a spokesperson for the Federal Department of Health and Ageing, every form of nicotine except for replacement therapies and cigarettes are classified as a form of poison. Last October, the National Drugs and Poisons Schedule Committee (NDPSC) decided that this classification should remain for e- cigarettes, which effectively makes it illegal to sell nicotine e- cigarettes in all states and territories. "The e- cigarette has not been evaluated for safety or efficacy," said a spokesperson for the Federal Department of Health and Ageing. "Nicotine has well recognized physiological and pathological effects and, as with conventional cigarettes, the e- cigarette would be expected to lead to, and sustain, nicotine addiction." htto:/ /www news com au /technology /electronic- cigarettes - sold- online- illegally /story- e6frfro0 -1111118601200 • March 2008, Turkey's Health Ministry bans the sale and importation of e- cigarettes, classifying e- cigarettes as a pesticide. Ads of ecigarettes are also banned. htto: / /arama.hurrivet .com.tr /orsivnews.aspx ?id =- 621407 and httr): // aroma. hurrivet . com.tr /arsivnews.asox ?id =- 622303 U.S. jurisdictions considering bans on the use and /or sale of e- cigarettes (alphabetical list by state). • On February 26, 2014 a San Diego Committee will consider a proposal to regulate electronic cigarettes as traditional cigarettes, including a ban in public places and workplaces and preventing the sale to minors. htto: // www .nigaso.org /ABC]ONewsSanDieao ecigs 2- 13- 14.pdf • On February 14, 2014 the West Virginia House passed a bill to ban the sale of electronic cigarettes and other alternative tobacco products to minors. It has been passed to the Senate for consideration. htto://www.wvaazette.com/News/­201402130118 • On February 22, 2013, California introduced a bill (SB 648) that would ban electronic cigarettes in public places and workplaces, amending existing smokefree air laws to include electronic cigarettes as tobacco products. http: / /www.leciinfo.ca.aov /pub /13 -14 /bill /sen /sb 0601 - 0650/sb 648 bill 20130805 amended asm v96.pdf • Since 2011, the San Francisco, California Department of Public Health has proposed holding e- cigarettes under the some public smoking laws as traditional tobacco products. The Health Commission passed a resolution on June 21, 2011 endorsing the San Francisco Department of Public Health's proposal to prohibit e- cigarettes where smoking is prohibited and would require a tobacco permit for the sale of e- cigarettes and other non -FDA approved smokirg cessation nicotine delivery devices. httip://www.sfbq.com/2013/06/12/scorninQ-smokers http: / /www.sfdph.or-a/doh /files /hc /HCRes /Resolutions /201 I Re5/ecig %20reso.pdf • In January 2014 Delaware proposed legislation banning the sale of e- cigarette products to minors. http : / /www.n6Qasp.orci /WDEL_I150am Minor Ban ecigs DE 1- 29- 14.pdf • In January 2014, Kentucky introduced HB220 to include electronic cigarettes in in the state's tobacco tax scheme, and HB267 to establish the age of sale as 18 for the sale of electronic cigarette devices. http: / /www.irc.ky.gov /record /14RS /"HB220.htm, http: / /www.irc.ky.gov /record/ 14RS /HB267.htm • As of September 2011, Macon, Georgia is considering the expansion of the state's smoking ban, which would also include banning the use of e- cigarettes in places where smoking is banned. htto : / / vww.breatheeasymocon.org /files /Ordinance.odf http: / /www,macon.com /201 1 /09/23/ 1 7 1 4992 / macon-at- odds - over- smokinq.html • In August 2013, Massachusetts proposed Bill 3639 to amend their existing smokefree air law to include e- cigarette,; and all nicotine delivery products and to restrict their sale of to people under 18 years of age, prohibit their use on public school grounds, prohibit free samples, ban their use in public places and workplaces, and restrict the distribution of samples. http : / /www.n*gaso.org /myfo ;(boston MA bill restricts ecigs 8- 13- 13.pdfl • In New Mexico, both the Santa Fe City Council and state legislators are considering legislation to ban the sale of e- cigarettes to minors as of November 2013. htto: / /www.niQasp.org /abaiournal.com ecigsale ban minors 11- 20- 13.pdf • In San Diego California, Sam Diego's Councilman Mark Kersey drafted a proposal to be considered by the city of fan Diego Committee asking that e- cigarettes be regulated the same way as traditional cigarettes and restrict the use of e- cigarettes in all public facilities. The proposal will be considered at the February 26 meeting.httr): / /www. l Orievvs.com/ news /son - diego- couricilmari- mark- kersey- pror)osal to -re ulate -e- cigarettes - 021314 • As of November 2013, Suffolk County, New York, is considering following New York City's lead by introducing a bill to raise the age of selling tobacco products to age 21. htto: / /www.n*Qaso.or /q CBS Suffolk Countv raise to 21 11- 21- 13.odf • On February 3, 2014, Oregon introduced HB 4115 to define "vapor product" and "vape" and amends laws related to consumption of tobacco products by minors to include references to consumption of vapor products by minors. It also bans the use of the devices indoors and in cars with children. t f l us.l /oiis,legstafe.or.us /liz /7U 14R 1 /Downloads /MeasureDocument /HB41 15 • On July 19, 2013 Pennsylvania introduced SB1055 to amend the definition of tobacco products to include electronic cigarettes. _ttt : /;eyi� _ul, coi.? !t tExtiSi_1u.5 73434 /Pennsylvania- 2013- SB1055- Introduced.Ddf • On January 16, 2014, Rhode Island introduced H7133 to include electronic cigarettes in the current tobacco product tax scheme. Also, H7021, introduced on January 8, 2014, would amend the definition of tobacco products to include e- cigarettes. http: / /Iegiscan.com /RI /text /F]7133/id/922758 /Rhode Isla nd - 2014- H7133- Introduced.pdf 12 httr): / /Iegiscan.com /RI /text /H7021 /id /907286 /Rhode Island - 2014- H7021- Introduced.odf • On January 27, 2014, Utah introduced SB 0012 to increase the age of sale to 21 for e- cigarettes and tobacco products. http: / /e.utah.aov/ -201 4 /bills /sbillint /S60012.odf International Jurisdictions considering bans on the use and /or sale of e- cigarettes (alphabetical list by country). • As of December 2013, the Phillipines is considering regulating the use and promotion of e- cigarettes, and regulating the sale to persons under 18 years old by introducing SB201 1 or the E- Cigarette Regulation Act of 2013. http:/ /www.riiQaso.orci/BusinessMirror Phillipines Senator seeks ecig reps 1- 3- 14.pdf • As of May 31, 2013, France is considering banning e- cigarette smoking in public places. http: / /www.nwaaso.orgICBSNews France ban ecias public places 5- 31- 13;pdf • As of December 2011, Greece is considering a ban on the sale and use of e- cigarettes. httio: / /www.ni_ciaso.org /Greece E -cig- ban - possible- 12- 13- 2011.pdf • As of June 2013, Italy is considering banning e- cigarette smoking in public places. htto:// www. niaaso .org /DNALifestyle- Iniurious to health Italy ecigs public 6- 6- 13.odf • On June 26, 2013, the Philippines' Food & Drug Association issued an Advisory that secondary exposure to e- cigarette emission might be harmful to health, and advised the public not to smoke or use e- cigarettes, and that local governing units shall be guided by this advisory in strengthening their ordinances against smoking in public places and on second -hand exposure to harmful substances." Read the Advisory for more details on the chemical and metals that pollute the air from e- cigarette vapor. ht�[www.fdc�., gay. t7h1�7t) achments .article/80233 /FA2013- 85,�cit The Tobacco Industry and E- Cigarettes Tobacco industry lobbyists are supporting bills that prevent sales to minors but are worded in such a way to ensure e- cigarettes remain taxed at a lower rate than traditional cigarettes and remain outside states' existing indoor smoking bans. In mid July 2013, Rhode Island Governor Chaffee vetoed a bill that banned the sale of e- cigarettes to minors, calling it "counterproductive to prohibit sales to children while simultaneously exempting electronic cigarettes from laws concerning regulation, enforcement, licensing or taxation. As a matter of public policy, electronic cigarette law' should mirror tobacco product laves not circumvent them '' httr):// www.n*aasr).org /ColumbusDisr)atch E -cig Bill Troian Horse 7- 22- 13.odf httr): / /www.tobaccofreekids.org /press releases /post /2013 07 18 ri In November 2013, The Wall Street Journal published an article "10 Things E- Cigarettes Won't Tell You" which looks at the e- cigarette industry as a threat to the decades of progress of antismoking efforts. The list of ten items with a brief description: 1. We're Big Tobacco in disguise. All three big tobacco companies (Altria Group, Reynolds American, and Lorillard) have entered the e- cigarette market. 2. We can't promise this won't kill you. The industry is careful only to claim their products are "less harmful" than traditional smokes. 3. This probably isn't the best way to quit smoking. They are not FDA approved as a 13 smoking- cessation product. 4. We're advertising like it's 1960 - while we still can. As of November 2013 the FDA has not yet issued regulations which could treat e- cigarettes under the same law as traditional cigarettes. 5. We defy categorization. The FDA regulations should sort this out if, as expected, e- cigarettes are classified as a tobacco product. 6. We're cheaper than cigarettes because we aren't taxed like cigarettes. 7. Kids love us. The proportion of middle- and high school kids who have used e- cigarettes doubled between 2011 and 2012, raising concerns that they can be a gateway to traditional smokes. 8. We're bringing smoking back indoors... 9. ...and back into aircraft. Some airlines have created policies banning smoking but the federal Department of Transportation currently doesn't ban e- cigarettes. 10. E- joints and e- crackpipes are the new e-cig. Liquid forms of some drugs are being created and used in the devices. http: / /www.nigasp .org /WallStJourna'_10_ Things ecigs 11- 20- 13.pdf As of November 2013, E- cigarettes do not fall under the some advertising restrictions as other tobacco products, and the companies have recreated the old product marketing strategies of using celebrity endorsements, cartoon characters, and flavors that appeal to kids such as chocolate and gummy bears. FDA regulations that are yet to be written may address this issue. 1111): www p.njgaso.ora /USATodaY ecigs ads I I- 11- I3_df On December 18, 2013 six Senators sent a letter to Federal Trade Commission Chairwoman Edith Ramirez requesting the FTC to investigate the marketing practices of e- cigarette manufacturers and urging enforcement action against companies that make misleading health claims in their advertising. htto: / /www.niciasp .org /BarbaraBoxer'ressRelease Eci-Q letter 12- 18- 13.pdf Why restrict sale and use of e- cigarettes? A September 3. 2013 article "9 Ter,ibly Disturbing Things About Electronic Cigarettes," in the Huffington Post lists them as: 1. E- cigarettes contain toxic chemicals. 2. Kids and teens can buy them. 3. While cigarette companies say they don't market to kids, e- cigarettes come in flavors like cherry, strawberry, vanilla and cookies and cream milkshake. 4. Laws regulating cigarette ads don't uet apply to e- cigarettes. 5. E- cigarette companies are spending a TON on advertising. 6. E- cigarettes can be used in many places where smoking is banned. 7. People think e- cigarettes can help them quit smoking. 8. E- cigarettes aren't taxed like traditional tobacco products. 9. Despite unknown health consequences, e- cigarettes are poised to make inroadsw with the new generation of young people. http: / /www.huffingtonpost.com /2013 /09 /03 /electroriic- cigarettes n 3818941.html ?view= priW&comm ref =false A University of Michigan poll released September 13, 2010 shows that adults support restrictions on e- cigarettes, based on potential risks and not just immediate health effect, as well as the possibility that e- cigarettes may lead youth to smoke cigarettes, according to Matthew M. Davis, 14 M.D., director of the poll. The poll found: • 91 percent of adults in the U.S. think manufacturers should be required to test e- cigarettes for safety. • 85 percent favor prohibiting the sale of e- cigarettes to minors. • 82 percent think the FDA should regulate e- cigarettes like other nicotine - containing products. • 68 percent of adults think e- cigarettes should have health warnings like tobacco cigarettes and other nicotine products. Read study at httr): / /www.med. umich. edu/ mott /npch /pdf /091310rer)ort.pdf. Read news clip at http: / /www.n*Qasr).orQ /e -Cigs- newswire- UMich- study- 9- 2010.r)df. II. Health Concerns The following sections provide detailed, documented support and information regarding public health concerns with e- cigarette use and exposure. 1. Product is 'smoked', therefore not permissible under the 2006 New Jersey Smoke -Free Air Act ( NJSFAA). The NJSFAA definitions section, NJSA 26:3D -57, defines smoking as "... or any other matter can be smoked ": "Smoking" means the burning of, inhaling from, exhaling the smoke from, or the possession of a lighted cigar, cigarette, pipe or any other matter or substance which contains tobacco or any other matter that can be smoked." The heating element in the e- cigarette heats and vaporizes the nicotine /propylene glycol solution, creating the 'smoke' which is inhaled and exhaled. Since the product is 'smoked' and creates a 'smoke', e- cigarette use is not permissible for use in public places and workplaces that are covered under the NJSFAA. In addition, some e- cigarette companies admit in their marketing materials that their products are 'smoked'. GASP surveyed some e- cigarette websites, and, for example, Smokeless Revolution's website admits many times, that the product creates a 'smoke': ''The EVO is an electronic, smokeless alternative that delivers true tobacco flavor through a vapor mist smoke, with your preferred level of nicotine." htto: / /www.smokelessrevolution .com /home.html Their website's "Frequently Asked Questions" section also states that a battery is used to create the smoke vapor: ...a small rechargeable battery and a unique, safe replaceable cartridge containing water, propylene glycol, nicotine, a scent that emulates a tobacco flavor and a membrane to suspend the ingredients. When using EVO, the act of inhaling or smoking it produces the tactile and craving satisfactions traditional smokers seek, and triggers a vaporizing process that releases a simulated smoke that is actually a vapor mist that harmlessly evaporates into the air within a few seconds. http: / /www.smokelessrevolution .com /faq.htmi 15 Other e- cigarette websites have similar language. 2. Public health nuisance created when product used as intended. The New Jersey general public nuisance code, NJSA 26:3 -46 et.seq. may also apply, separate and apart from the NJSFAA. It is unclear what byproducts are in the smoke that is emitted from the e- cigarette, and therefore, thE� safety of the smoke is called into question. NJSA 26:3 -46 specifically refers to "gases or vap(Drs... that are injurious to the health of the inhabitants." Persons with breathing disabilities may especially have their lung functioning compromised, due to exposure to e- cigarette byproducts like propylene glycol (helps to create the smoke effect), and other additives to the nicotine solution when heated, then dispersed into the air. A public place or workplace that permits the usage of e- cigarettes may be subject to a violation of the NJ Law Against Discrimination, or the Americans with Disabilities Act Amendment Act of 2009. Pertinent sections of the NJ public health nuisance code are in section 14 of this paper. On January 24, 2011 an Allegiant Airlines flight was diverted when a passenger refused to stop using their e- cigarette in- flight. The passenger argued with the flight attendant, and the pilots diverted the plane. htto: / /www.wv(�c.com/ home / Electronic - cigarette- leads -to- unexpected - landing -in- Norfolk -1 14504289.html 3. July 2009 FDA study finds carcinogens in e- cigarettes, and other health concerns regarding the use of e- cigarettes. The FDA's Center for Drug Evaluation, Division of Pharmaceutical Analysis (DPA) conducted a laboratory analysis of e- cigarette cartridges from two leading brands. The analysis indicated that e- cigarettes expose users to harmful chemical ingredients: • Diethylene glycol, an antifreeze ingredient toxic to humans was found. • Tobacco specific nitrosamines that are human carcinogens were detected in '/2 of the samples. • Tobacco - specific impurities suspected of being harmful to humans - anabasine, myosmine, and B- nicolyrine - were detected in a majority of the samples. • The e- cigarette cartridges labeled as containing no nicotine had low levels of nicotine present in all cartridges sampled, except one. • 3 different e- cigarette cartridges with the same label emitted markedly different amounts of nicotine with each puff, ranging from 26.8 to 43.2 mcg nicotine/ 100 ml puff. • One high- nicotine cartridge delivered twice as much nicotine to users when inhaled, than was delivered by a sample of an FDA approved smoking cessation nicotine inhalation product. FDA Summary htto: / /wevw. fda. aov/ NewsEverits/ PublicHeaithFocus /ucml73146.htm FDA study htto: / /www.fcta.gov/ downloads/ Druas /ScienceResearch /UCM173250.pdf The FDA concluded in its July 2005' findings • Clinical studies about the safety and efficacy of these products for their intended use have NOT been submittec to the FDA. Consumers have now way of knowing: • Whether e- cigarettes are safe for their intended use. • About what types or concentrations of potentially harmful chemicals, or what dose of nicotine they are inhaling when they use these products. http: / /www.fda.govi ForConsumers /ConsumerUpdaies /ucm 173401.him • Read highlights from the FDA July 2009 media call in section 13 of this paper. U.S. Senator Frank Lautenberg issLed a July 22, 2009 press release in response to the FDA report: 16 This report proves what we feared - that e- cigarettes may be unsafe and need to be taken off the market immediately. Not only can these products fuel a life -long addiction to nicotine, but now the FDA has found that they contain cancer - causing chemicals. http: / /www.nigaso.oici /Ecicis sen lautenberg press release 03- 23- 09.pdf National Public Radio quoted Walt Linscott, an attorney for Smoking Everywhere, a major e- cigarette importer, in their August 5, 2009 story about e- cigarette: "It is a cigarette, and cigarettes inherent by their design and nature are not safe." http: / /www.r)igaso.org /NPR ecigs 08- 05- 09.L�ai 4. World Health Organization (WHO) issues warnings about e- cigarettes. At an annual awards ceremony held July 2, 2013, the WHO urged the government of the Philippines to regulate the sale of e- cigarettes, citing a trend in other countries where people who started using e- cigarettes ended up smoking the real thing. Dr. Susan Mercado, director for Building Healthy Communities and Populations of the WHO - Western Pacific office said, "In 2010, the WHO organized a global panel of experts to review the evidence and there is no evidence to show that it can help you quit smoking," milt D: www,niQaso.org Philhooines WHO ecigs warning /413.odr. In September 2008, the WHO issued a written warning that there is no research /testing that e- cigarettes are safe products for human consumption, and no evidence that e- cigarettes are a safe substitute for smoking, or help smokers to quit. See WHO statement at htto: / /www.who.int /mediacenire /news /releases /2008 /pr34 /en /ir)dex.litmi. 5. Researchers, health organizations voice concerns about e- cigarettes. In the June 2014 issue of ASHRAE Journal, Bud Offerman, an expert on indoor air, published a risk assessment of exposure to electronic cigarette vapor. The study concluded that e- cigarettes emit harmful chemicals into the air and need to be regulated in the same manner as tobacco smoking. htto: / /www.niQasr).orci/ashrae - journal- study- concludes -e- cigarette - vaoor- harmful/ In May 2014, The Journal Circulation published a "Cardiology Patient Page" on Electronic Cigarettes. Key information: • A short -term exposure study showed that 5 minutes of e- cigarette use resulted in a significant increase in airway flow resistance, which, although of unknown clinical significance, does not support the claim the product is harmless. Vardavas Cl, Anagnostopoulos N, Kougias M, Evangelopoulou V, ConnollyGN, Behrakis P K. Short -term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest. 2012;141:1400 - 1406, originally published in June 2012 Tobacco Cessation and Prevention. • Nonsmokers (persons who do not use tobacco cigarettes or e- cigarettes) who are exposed to the exhaled, or secondhand, e- cigarette aerosol have measurable levels of the nicotine metabolite cotinine in their blood. See Grana R, Benowitz N, Glantz SA. E- cigarettes: a scientific review. Circulation.2014;129:1972 -1986. • A review of 5 studies showed that smokers who used e- cigarettes were less likely to quit smoking than smokers who did not use e- cigarettes. See Grana R, Benowitz N, Glantz SA. E- cigarettes: a scientific review. Circulation.2014;129:1972 -1986. 17 • To avoid reversing the effectiveness of these policies, e- cigarettes should not be used anyplace where smoking cigarettes is not allowed (including in homes that are smoke - free). There is no reason to reintroduce toxins into clean indoor air environments. • To prevent youth initiation, e- cigarette advertising should be subject to the some restrictions (including beino prohibited on television and radio) as cigarette advertising, and the use of flavors should be prohibited. • "If someone is already using e- cigarettes to quit smoking, support the quit attempt, and encourage him or her to quit all tobacco cigarette use, emphasizing the lack of reduction in health risks from dual use. Inform him or her that e- cigarettes are not approved by the US Food and Drug Administration for smoking cessation. • The limited research published to date has not proven that electronic cigarettes are effective smoking cessation aids. Inform patients that e- cigarettes are unregulated and that users cannot be sure what they are exposed to. Given the lack of knowledge about long -term risks and potential harms, patients should also be urged to set a quit date for their e- cigarette use." [page e491 j On March 4, 2014, the New York Times story "E- Cigarettes, by Other Names, Lure Young and Worry Expert" discussed the growi ,)g trend of non - traditional electronic cigarettes. "Hookah pens," "e- hookahs," and "vape pipes ", subdivisions of electronic cigarettes, are growing in popularity among minors and causing trouble for health officials who are facing struggles trying to regulate and measure the spread of e- cigarettes. The worry is that many users of these products don't realize that they a-e off -sets of electronic cigarettes which is leading to under reported use in national and local studies of electronic smoking devices. http: / /www.nygasp,org /NYTimes ecgs other names 3- 4 -14.ndf In a February 5, 2014 letter to the British Medical Journal from Mari Roberts and Mark Davies from the Department of Anesthesia, Rcyal Liverpool and Broadgreen University Hospitals, the dangers of electronic cigarette use before surgery are discussed. Traditionally, anesthesiologists have strongly advised patients to stop smoking before anesthesia and surgery, and now some doctors are also recommended avoiding electronic cigarette use prior to surgery. Electronic cigarettes, like traditional cigarettes, provide users which nicotine, which can affect the cardiovascular and nervous systems, making the process of anesthesia less predictable and less safe. htto: / /www.niaasD.org a dancers 2- 5- 14.pdf The January 7, 2014 issue of the American Journal of Preventive Medicine published the study, "Beliefs and Experimentation with Electronic Cigarettes." The researchers concluded: "Given that young adults are still developing their tobacco use behaviors, informing them about the lack of evidence to support e- cigarettes as quit aids and the unknown health risk of e- cigarettes may deter young adults from tryirg these products. L) L, _oij /­ �hi I umenre /AMEPRE 3935- stamyed- 010714.pdf In a National Center for Biotechnology Information study, published December 22, 2011, the acute pulmonary effects of using an e- cigarette were examined. The study found that there are immediate adverse physiologic effects after short -term use of electronic cigarettes that are similar to some of the effects seer with tobacco smoking. In the December 11, 2013 issue of the journal Nicotine & Tobacco Research, Roswell Park Cancer Institute released their study on secondhand vapor smoke entitled, "Secondhand Exposure to Vapors from Electronic Cigarettes ". The "results showed that e- cigarettes emitted significant amounts of nicotine." The researchers share that this raises health concerns about a nonuser's exposure to secondhand vapor smoke. The researchers conclude that their study can "guide policymakers as decisions are made about the regulation of nicotine delivery devices. Study observations also include: • This study focused on nicotine and a limited number of chemicals released from e cigarettes. Future research should explore emissions and exposures to other toxins and EK01 compounds identified in e- cigarettes such as formaldehyde, acetaldehyde and acrolein. • Data also are needed to determine whether secondhand exposure to e- cigarette vapors results in reinforcement of nicotine addiction. • More research is needed to investigate whether the vapor from e- cigarettes is deposited on surfaces to form `thirdhand' e- cigarette vapor. • "Our data suggest that secondhand exposure to nicotine from e- cigarettes is on average 10 times less than from tobacco smoke. However, more research is needed to evaluate the health consequences of secondhand exposure to nicotine from e- cigarettes, especially, among vulnerable populations including children, pregnant women and people with cardiovascular conditions." • "Questions remain regarding the health impact of e- cigarettes among smokers and nonsmokers. It remains unclear whether young people will see e- cigarette use as a social norm and if e- cigarettes will be used as sources of nicotine in places with smoking bans, thus circumventing tobacco -free laws," said Andrew Hyland, PhD, Chair of the Department of Health Behavior at RPCI. • "This study and others can guide policymakers as decisions are made about the regulation of the nicotine delivery devices." Roswell Park's research partners include the Medical University of Silesia in Sosnoewiec, Poland; and the Department of Chemical Hazards / Institute of Occupational and Environmental Health in Sosnowiec, Poland. htto: / /www.nj ag sp.org /NTR Czogala- Goniewicz- Travers SHS e -cig vapors 12- 2013.gdf On December 3, 2013, the Dutch Health Ministry's National Institute for Public Health issued an "E- Cigarette Factsheet" about concerns with safety, quality, sales and endorsement of e- cigarettes. The Factsheet details e- cigarette ingredients that may irritate the respiratory system, and some ingredients that contain carcinogenic substances like formaldehyde and tobacco - specific nitrosamines. Fox News reported that, "Citing the institute's findings, Dutch deputy health minister Martin Van Rijn argued that e- cigarettes are as addictive as tobacco cigarettes because they contain nicotine, and he said there was no proof of claims by manufacturers that they help smokers quit." • Read the Factsheet i tt : www.rivm.nl dsresou(ce ?objectid- rivLilLI 230 /04 &tyoe_orQ &disposition= inline &ns nc =1 • Read the Dutch Ministry of Health's summary webpage http: / /www.rivni.nl /en /Documents and publications /Common and Present /Further research into hazards posed by e cigarettes http://www.rivm.nilen/Documer)ts and oublications /Common and Present /Further research into hazards posed by e cigarettes? • Read the Fox News 1 1/29/13 story Wtp;1lwww,foxnzy�s corn[health.[20�_I 1 /29(�iutch- sound_ alarm - about- r)ossible_risks-e- cigarette / The November 2013 issue of the National Institute on Drug Abuse's publication, DrugFacts, included an article on the public health implications of using electronic smoking devices. Based on their research, NIDA concluded: • Some people believe e- cigarette products may help smokers lower nicotine cravings while they are trying to discontinue their tobacco use. However, at this point it is unclear whether e- cigarettes may be effective as smoking- cessation aids. There is also the possibility that they could perpetuate the nicotine addiction and thus interfere with quitting. • Because e- cigarettes are not currently marketed either as tobacco products or as devices having a therapeutic purpose, they are not regulated by the FDA. In addition, there is currently no regulation of the liquids that are used in e- cigarettes. So, there are no accepted measures to confirm their purity or safety. • These products have not been thoroughly evaluated in scientific studies. This may change in the near future, but for now, very little data exists on the safety of e- cigarettes, and consumers have no way of knowing whether their purported therapeutic benefits or 19 advantages over conventional cigarettes are real. http: / /www.n*gaso.orgznovember -2013- issue -of- the - national- institute -on- drug- abuses- publication- drugfacts- looks- into- e -cias/ On November 28, 2013, the European Commission announced that it seeks to overturn a vote by Members of the European Parliament that rejected outlawing electronic smoking devices in their present form. Brussels officials fear that there is a "risk that electronic cigarettes can develop into a gateway to normal cigarettes ", according to the paper, and wants to include the smoke - free alternative under a new EU "tobacco products directive" — despite the fact that they contain no tobacco. The commission proposals would ban, by 2017, e- cigarettes that produce levels of nicotine above 20 mg per nil, those with refillable cartridges or those designed to taste like tobacco. According industry Estimates, if current growth rates continue, by 2017, when the EU ban would come into force, there could be nearly five million former people using electronic cigarettes rather than smoking tobacco. In Britain, the pub chain JD Wetherspoon and some train operators have already banned the devices. The Dutch public health institute on Wednesday published a policy paper claiming that electronic cigarettes are as harmful as ordinary cigarettes, warning they are addictive and contain poisonous substances: • The European Commission document says the devices "normalise the action of smoking ". • They simulate smoking behaviour and are increasingly used and marketed to young people and non - smokers. ". hlir?. w r felE:grc �h.�o.ukln vvs'.vO�iiil_,',- leuroL)e /eu/ 10481328 /EU- seeks- bun -ori- ail- currentiv- avc�il _nl�le- F:_cigc�rettes.html An April 2013 study be the German Cancer Research Center (DKFZ) evaluated the current state of e- cigarettes. The Key Message of the research center publication is: "Electronic cigarettes are novel products emerging on the market just a couple of years ago. Consequently, there are only few scientific studies on the health implications of using electronic cigarettes. Based on current data, the following statements can be made: Product characteristics • E- cigarettes cannot be rated as safe at the present time. • Consumers do not have reliable information on product quality. • Electronic cigarettes have various technical flaws (leaking cartridges, accidental intake of nicotine when replacing cartridges, possibility of unintended overdose). • Some manufacturE�rs provide insufficient and partly wrong information about their liquids. Health effects • The liquids contain ingredients that on short -term use irritate air- ways and may lead to allergic reactions and which may be harmful to health when inhaled repeatedly over a orolonged period of time. • The aerosol of some liquids contains harmful substances (form- aldehyde, acetaldehyde, acrolein, diethylene glycol, nickel, chromium, lead). • The functionality of electronic cigarettes can vary considerably (aero- sol production, nicotine delivery into aerosols). • Adverse health effects for third parties exposed cannot be excluded because the use of electronic cigarettes leads to emission of fine and ultrafine inhalable liquid particles, nicotine and cancer - causing sub- stances into indoor air. Users of electronic cigarellhes • Smokers and smokers considering cessation, as well as former smokers use electronic cigarettjes predominantly. • Even though only flew non - smokers use electronic cigarettes, the products may 20 bring them closer to smoking conventional cigarettes. Electronic cigarettes are used as an alternative to cigarette smoking and as smoking cessation aids primarily because they are believed to be less harmful than regular cigarettes. Efficacy as cessation device • Electronic cigarettes - regardless of their nicotine content - can reduce the desire to smoke (craving) and withdrawal symptoms. • Some smokers cut down smoking or quit smoking as a result of using e- cigarettes. • The efficacy of e- cigarettes as an aid for sustained smoking cessation has not yet been proven. Product regulation • We desperately need to know more on product quality, ingredients, possible health effects of e- cigarette use, and efficacy of e- cigarettes as cessation aid. Carefully planned studies by qualified and objective scientists are necessary. • Electronic cigarettes should be regulated as medicinal products, regardless of their nicotine content. • E- cigarettes should not be dispensed to children and youth. • Non - smoker protection legislation should apply to e- cigarettes." htto: / /www.dkfz.de /en /presse /download /RS- Vol19- E- Cigarettes- EN.pdf In the March 20, 2013 issue of the journal PLOS ONE, researchers from the University of California - Riverside published their study entitled, "Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol." The researchers found that 22 elements were identified in the electronic cigarette aerosol, and three of these elements (lead, nickel, and chromium) appear on the FDA's "harmful and potentially harmful chemicals" list [38]. The researchers concluded that EC consumers should be aware of the metal and silicate particles in EC aerosol and the potential health risks associated with their inhalation: Lead and chromium concentrations in EC aerosols were within the range of conventional cigarettes, while nickel was about 2 -100 times higher in concentration in EC aerosol than in Marlboro brand cigarettes (Table 1). • Adverse health effects in the respiratory and nervous systems can be produced by many of the elements in Table 1, and many of the respiratory and ocular symptoms caused by these elements have been reported by EC users in the Health and Safety Forum on the Electronic Cigarette Forum website http' / /www_e- cigarette _ forum .com /forum /health- safety -e- smokin • Although Table 1 was constructed to emphasize the effects of the elements found in aerosol on the respiratory system, other systems, such as the cardiovascular and reproductive systems, can be affected by most of the elements in EC aerosol. • Nanoparticles tend to penetrate deep into the respiratory system and reach the alveolar sacs. The electronic cigarette brand used in our study required a high air flow rate to produce aerosol, which would further enhance deep penetration of nanoparticles into the respiratory system. Metal particles /nanoparticles can produce adverse effects in vitro and in vivo, and nanoparticles can be transported in vivo to other organs, including the liver, kidney, heart, and brain. Chromium, nickel and tin nanoparticles were found in EC aerosol. Cobalt chromium and chromium oxide nanoparticles damaged cultured cells, and long -term inhalation of nickel hydroxide nonoparticles by mice caused oxidative stress and inflammation in lung and cardiac: tissues. While tin nanoparticles, per se, have not been studied in human lungs, tin dust from a Chinese mine was cytotoxic. induced release of reactive oxygen species from alveolar macrophages in vitro, and induced malignant transformation of cultured bronchial epithelial cells. Inhalation of tin dust has also been reported to cause stannosis in humans. • The study was based on one brand of electronic cigarettes purchased on multiple occasions over a two year period. It will be important in future studies to determine if other brands of EC produce aerosol with 21 similar levels of metals and silicates and if the metals, silicates and nanoparticles in EC aerosol present long -term health risks to users and exposed bystanders. Study citation: Williams M, Villarreal A. Bozhilov K, Lin S, Talbot P (2013) Me al and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol. PLoS ONE 8(3): e57987. doi :10.1371 /journal.pone.0057987 In the March 6, 2013 issue of the journal Tobacco Control, Roswell Park Cancer Institute released their study on carcinogens and toxicants in secondhand vapor smoke entitled, "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes." The study found that as a harm reduction strategy, a nicotine inhaler would be a safer approach to delivering nicotine than an e- cigarette product. The study results comparing the two products show: Toxic Compounds E-cig Inhaler Formaldehyde 28.9 2.0 Acetaldehyde 7.4 1.1 Acrolein 11.5 ND o- methylbenzyne 3.9 0.7 Toluene 0.8 ND p,m- xylene 0.1 ND NNN 1.5 ND NNK 6.6 ND Cadmium 0.09 0.03 Nickel 0.19 0.19 Lead 0.09 0.04 ND =not detected Accordingly, an e- cigarette delivers 14 times as much formaldehyde, 7 times as much acetaldehyde, 6 times as much o- methylbenzene, 3 times as much cadmium and twice as much lead as a nicotine inhaler, cis well as acrolein, toulene, p,m- xylene, NNN and NNK, which were not detected in the inhaler. Roswell Park's research partners include the Medical University of Silesia in Sosnoewiec, Poland; and the Department of Chemical Hazards / Institute of Occupational and Environmental Health in Sosnowiec, Poland. Read more on the Center for Tobacco Control Research & Education's website. htto:// tobaccocontrol .bme.com /contentJearly /2013 /03/05 /tobaccocontrol - 2012- 050859.abstract A March 13, 2013 New York Daily News article identifies e- cigarettes as being tried by about 21% of adult smokers in 2011, up from 10% in 2010. According to Dr. Andrew Strasser, associate professor in the department of psychiatry at the University of Pennsylvania School of Medicine, and resident tobacco products expert at Penn's Center for Interdisciplinary Research on Nicotine Addiction: • "Just replacing some of your daily cigarettes [with e- cigarettes] is not really a harm reduction strategy." • "There has not been a rigorous evaluation of quality control." • "There could be a significant variation in nicotine dosing in individual cartridges." • "We don't know enough a oout the e- cigarette to be able to recommend it as a smoking cessation tool" Read the full article at http : / /www.njaasp.orQ /NYDailyNews More people are smoking e- cigarettes but as a Quitting tool they may be all smoke and mirrors 3- 13- 13.pdf The May 2013 issue of the journal Nicotine & Tobacco Research published a study entitled, "UHF: of Electronic Ciclarelles Among Slaie Tobacco Cessation Quinine Callers ", which found that smokers trying to quit who used e- cigarettes were significantly less likely to be tobacco abstinent at the 7 -month survey, compared with participants who had never tried e- cigarettes. Read a list of implications from the study published by Dr. Stan Glantz of the University of California, San Francisco Center for Tobacco Control Research & Education. htto: / /tobacco.ucsf.edu /important- new- evidence - using -e- cigarettes- reduces - successful- auitting- 22 0 cigarettes The Italian Health Ministry published a report on December 28, 2012 that concludes e- cigarettes do not help smokers quit, nor do they provide a safer alternative to traditional smoking. Roberto CW Pacifici, director of Italy Observatory on Smoking, Alcohol and Drug Use at the National Health Institute, who worked on the report, said that the scientific reports studied "do not reassure us about the effectiveness or the innocuousness of its use." httg: / /www.njciaso.org /ABC no proof e -cigs combat addiction 1- 2- 13.odf A University of Athens study was presented at the European Respiratory Society's Annual Congress in Vienna, Austria on September 2, 2012. • The study showed that using an e- cigarette caused an immediate increase in airway resistance, lasting for 10 minutes, making it harder for participants to breathe. • "We found an immediate rise in airway resistance in our group of participants, which suggests e- cigarettes can cause immediate harm after smoking the device. More research is needed to understand whether this harm also has lasting effects in the long- term. htto: / /www.ersconaress20l 2.ora /mediacenter/ news - release /item/ 428 - experts -warn- that -e- cigarettes -can- damage- the- lungs.html • "ERS does not classify e- cigarettes as a safe alternative to smoking, nor does it consider them an approved tobacco cessation tool," spokesman Klaus Rabe recently told reporters, reiterating from the society's statement in February. "ERS recommends following effective smoking cessation treatment guidelines based on clinical evidence which do not advocate the use of such products." htto://www.dailycommercial.com/091112electronicciQarettes httr): / /www.medicalnewstoday.com /articles /249784.r)hp The August 1, 2012 edition of the Oxford University Press on behalf of the Society for Research on Nicotine or Tobacco 2012 published FDA's letter entitled, FDA Summary of Adverse Events on Electronic Cigarettes. The letter was submitted by Ii-Lun Chen, MD, Office of Science, Center for Tobacco Products, FDA. The types of adverse effects from e- cigarettes reported to the FDA are: "2008 and earlier (1 of 18 total tobacco product reports), 2009 (10 of 16), 2010 (16 of 27), 2011 (1 1 of 30), and first - quarter 2012 (9 of 11). Of the 47 reports on e- cigarettes, 8 reported serious adverse events. A summary of serious e- cigarette complaints include hospitalization for illnesses such as pneumonia, congestive heart failure, disorientation, seizure, hypotension, possible aspiration pneumonia, second - degree burns to the face (product exploded in consumer's mouth while driving and during routine use), chest pain and rapid heartbeat, possible infant death secondary to choking on e -cig cartridge, and loss of vision requiring surgery." "In addition to these serious adverse events, other e- cigarette complaints include concerns about false advertising, headache/ migraine, chest pain, cough /sputum, nausea /vomiting, dizzi- ness, feeling sick, confusion /stupor, sore throat, shortness of breath, abdominal pain, pleurisy, blurry vision, and sleepy /tired. Of note, there is not necessarily a causal relationship between AEs reported and e- cigarette use, as some AEs could be related to pre- existing conditions or due to other causes not reported." "Research by CTP reviewers found e- cigarette companies marketing flavored cartridges containing nicotine levels ranging from 0 mg to upwards of 24 mg...". A July 2012 study published in the journal Indoor Air found that e- cigarettes are putting detectable levels of significant carcinogens and toxins into the air: acetic acid, acetone, isoprene, formaldehyde and acetaldehyde. The authors concluded "[t]he consumption of e- cigarettes marks a new source for chemical and aerosol exposure in the indoor environment. To 23 evaluate the impact of e- cigarettes on indoor air quality and to estimate the possible effect of passive vaping, information abou' the chemical characteristics of the released vapor is needed." The study was conductE�d at the Fraunhofer Wilhelm- Klauditz- Institut in Germany. htto: / /www.niQaso.org /Indoor Air journal ecig vaping 5- 2012.odf In July 2011, The New England Journal of Medicine published a perspective from the Schroeder National Institute for Tobacco Research and Policy Studies which discusses safety concerns with e- cigarettes. According to the Legacy Foundation's press release: • "Smokers attempting to use e- cigarettes as quitting aids will most likely find them ineffective due to the fluctuating nicotine content and unpredictable delivery." • "The safety of inhaling projoylene glycol over an extended period of time has not been studied in humans." • "E- cigarettes may serve a! a 'bridge product' that smokers use in places where traditional tobacco smoking is prohibited, thus perpetuating their addiction and use of real cigarettes." • E- cigarettes "may be used as a 'starter' product for young people considering smoking, especially since the cartridges can be purchased over the Internet with tempting flavoring like grape and chocolate." htto://www.legacyforhealth.arg/4551).aspx In December 2010, a study funded by a grant from the University of California Tobacco - Related Disease Research Center studied 5 brands of e- cigarettes and observed many safety issues: • "Batteries, atomizers, cartridges, cartridge wrappers, packs and instruction manuals lack important informction regarding e- cigarette content, use and essential warnings; • "E- cigarette cartridges leak, which could expose nicotine, an addictive and dangerous chemical, to children, adults, pets and the environment; • "Currently, there are no methods for proper disposal of e- cigarettes products and accessories, including cartridges, which could result in nicotine contamination from discarded cartridges entering water sources and soil, and adversely impacting the environment; and • "The manufacture, quality control, sales, and advertisement of e- cigarettes are unregulated." These researchers expressed their concern about the safety of the e- cigarette vapors. The University of California press release states: "Contrary to the claims of the manufacturers and marketers of e- cigarettes being 'safe,' in fact, virtually nothing is known about the toxicity of the vapors generated by these e- cigarettes. Until we know any thing about the potential health risks of the toxins generated upon hecting the nicotine - containing content of the e- cigarette cartridges, the 'safety' claims of the manufacturers are dubious at best." htto: / /www.n4gaso.org /e -cig study UC Riverside 12- 3- 2010.odf The e- cigarette device can be dangerous. An electronic cigarette plugged into a laptop for charging exploded and started a fire in an Idaho residence. htto: / /www.nigaso.ora /WPTV ecig fire Idaho 11- 5- 13.odf A Florida user lost teeth and part of his tongue when an e- cigarette battery malfunctioned, blowing up in his mouth and causing a fire in his home. htto: / /www.niQaso.orQ /ABCNews ECiq_Explodes 2- 17- 2012.odf The December 2010 issue of the American Public Health Association Journal published an editorial expressing health concerns about e- cigarettes. fittp: / /www.nigaso.org /APJA ecig editorial 12- 2010.odf 24 ` 1 Harvard School of Public Health's industry watch entitled, "Electronic Cigarettes: A new 'tobacco' industry ?" published October 7, 2010 concludes: "Research on product design, toxicant exposure, abuse liability including dual use with tobacco products, youth initiation, and influence on cessation efforts is needed to counteract e- cigarette industry marketing and inform regulatory strategies." htto: / /www.nociaso.org/TC ecig industry 10- 25- 2010.pdf On August 27, 2010, The American Cancer Society Cancer Action Network presented to the New Mexico Tobacco Settlement Revenue Oversight Committee asking for a ban of all sales of e- cigarettes until approved by the FDA. On June 14, 2010, The American Medical Association (AMA) House of Delegates adopted a new policy that recommends electronic cigarettes (e- cigarettes) be classified as drug delivery devices, subject to the same FDA regulations as all other drug delivery devices. Additional policy adopted supports prohibiting the sale of e- cigarettes that are not FDA approved. AMA Board Member Edward L. Langston, MD, stated: "Very little data exists on the safety of e- cigarettes, and the FDA has warned that they are potentially addicting and contain harmful toxins." "Because e- cigarettes have not been thoroughly tested, one cannot conclude that they are less harmful or less dangerous than conventional cigarettes." "The fact that they come in fruit and candy flavors gives them the potential to entice new nicotine users, especially teens." h_ttp: / /www.nigasp.org /AMA ecigs drug delivery 06- 14- 10.pdf In May 2010, support of an Illinois bill that would ban the sale of electronic cigarettes (SB 3174), national public health organizations issued a public statement with 3 key messages about this product that is not regulated by the FDA: "There is no scientific evidence that e- cigarettes are safer for consumers than regular tobacco products "; "Many e- cigarettes are being enhanced with bubble gum and fruit flavors, which are attractive to teens. "; "There is no scientific evidence that e- cigarettes can help smokers quit." http: //www.iafQ.com/ legislative /SB3174e- cigarettes.pdf In May 2009, the American Lung Association, American Cancer Society Cancer Action Network, the American Heart Association, and the Campaign for Tobacco -Free Kids have called for e- cigarettes to be removed from the market. See FDA website. htto://www.fda.gov/NewsEvents/PublicHealthFocus/ucml 73175.htm On July 9, 2014 Forum of International Respiratory Societies (FIRS) issued its position statement on electronic smoking devices and calls for bans or restrictions on the product including: • "Electronic nicotine delivery devices should be restricted or banned, at least until more information about their safety is available. • Adverse health effects for third parties exposed to the emissions of electronic cigarettes cannot be excluded." http: / /www.atsiourrials.ora /doi /abs/ 10.1 164 /rccm.201 407 -1 1 98PP 6. E- cigarettes appeal to youth. The Utah State Department of Health published in December 2013 the results of their state survey on tobacco product use, which shows a much higher level of use among kids than adults. Here are their conclusions: • The percentage of Utah students in grades 8, 10, and 12 who reported that they had tried electronic cigarettes more than doubled from 2011 to 2013 • Despite having no legal access to e- cigarettes, Utah youth are three times more likely to report current use than adults • Nearly one third of Utah youth who used e- cigarettes in the past 30 days report that they 25 never tried conventional cigarettes • Due to candy -like flavors, aggressive marketing, and lack of data regarding safety, monitoring the increasing ,ise of e- cigarettes among youth is a public health priority htt[p: / /health.utah.aov /opha /publications /hsu/ 1312 ECi__c].pdf On September 6, 2013 the Centers for Disease Control and Prevention reported that during 201 1- 12, e- cigarette use and experimentation more than doubled among U.S. middle and high school students. Results from the National Youth Tobacco Survey show that the percentage of high school students who reported ever using e- cigarettes increased from 4.7 percent in 2011 to 10 percent in 2012. According to the report, approximately 1.78 million U.S. youth used e- cigarettes in 2012. To summarize, • 10 percent of high school students have tried e- cigarettes • Middle and high school e- cigarette use doubled from 2011 to 2012 • In 2012, an estimated 160,000 middle and high school students who tried e- cigarettes have never smoked a cigarette. htto: / /www.cdc.aov /mmwr /preview /mmwrhtml /mm6235a6.htm Youth are attracted to electronic gadgets. Coupled with e- cigarette flavorings that are enticing to teens and children, there is concern that e- cigarettes smoking may appeal to teens, and also lead teens to smoking cigarettes, little cigars that look like cigarettes, or other tobacco products, which are less expensive than e- cigarettes. See health organizations concerns at htto: // www. fda. aov /NewsEvents /PuLlicHealti)Focus /ucm 1 731 Z5.1)trr1 New electronic smoking devices, such as "hookah pens ", can appeal to minors. They are colorful, come in fruit and candy 1avors, and allow the smoker to be discreet in their usage around parents or other adults in school situations. For an example: htto: // www. texashookoh. com /imagErs /disgosablehookah.htm A study published July 2012 in the American Journal of Public Health entitled "Young Adults' Favorable Perceptions of Snus, Dissolvable Tobacco Products. and Electronic Cigarettes: Findings From a Focus Group Study" concludes: "Young adults perceive the new tobacco products positively and are willing to experiment with them. Eliminating flavors in these products may reduce young adults' intentions to try these products." http : //njgas_.ora /AmJPubIICHealtll cbstract ecii s young adults 7- 19- 12.pdf The FDA and health advocates are concerned about the appeal of e- cigarettes to young people. The FDA July 2009 report stated: • E- cigarettes can increase nicotine addiction among young people and may lead kids to try other tobacco producs, including conventional cigarettes, which are known to cause disease and lead to premature death. f)tto://www.fda.qov/ForCon umers/CarisumerUodates/ucm]73401.htm The liquid nicotine solution, packaged in a separate bottle, can be consumed by a child, and lead to nicotine poisoning, as in this case where it was reported that a child died after swallowing her grandfather's liquid e- cigarette nicotine cartridge. http : / /www.nicna�.ora/TimesofIsrael toddler ecia nicotine death 5- 29- 13.odf 7. Unsubstantiated claims about e- cigarettes' reduced health risk. In 2011, about 21 percent of adults who smoke traditional cigarettes had used electronic cigarettes up from about 10 percent in 2010. I)ttip://www.cdc.gov/media/­releaseSL201.3/gO228._electronic cigarettes.html Employers are beginning to assess a health insurance plan surcharge for employees using e- cigarettes. According to the National Business Group on Health, using e- cigarettes is tobacco use and should be treated as such by employers. In 2014, UPS will charge employees $150 per 26 month more for their health plan, if they use tobacco, including e- cigarettes. Wal -Mart also places employees who use e- cigarettes in their health plan's "tobacco user" classification; their health plan has two classifications: non - tobacco user and tobacco user. In 2013, 42% of employers added a monthly surcharge for tobacco -using employees. http:// www.nigaso.org /ModernHealtticare employers ins charge ecigs smoking 8- 29- 13.pdf htto: // www. nigasQ .org /CiricinattiBusinessCourier ecig health insur 9- 13- 13.pdf Federal, state, county and local policymakers are concerned about claims of reduced health risk when using e- cigarettes. The e- cigarette companies have NOT provided any scientific clinical studies and toxicity analyses to the FDA that demonstrate reduced health risk, or that the product is safe to use. See public health advocacy organizations concerns at litto://www.fdc).qov/NewsEvents/PublicHealtiiFocus/­`ucnil 73175.htm For example, an October 24, 2009 press release from Denver -based E- CigaretteDirect.com states: "E- CigaretteDirect.com recommends that smokers switch to electronic cigarettes to protect themselves and their loved ones from secondhand smoke and heart disease... The electronic cigarette takes all the smell, and detrimental health risks out of the picture. The e- cigarette is considered a harm reduction alternative to regular cigarettes." htto : / /www.nigasr).org /Ecigdirect press release 10- 24- 09.pdf The e- cigarette industry opposes smokefree air laws that are proposed in states without comprehensive smokefree air laws, and encourages e- cigarette usage on airplanes, which are confined spaces with recirculated air. An e- cigarette buyer's guide blog details how an airplane passenger should convince a flight attendant to let them smoke e- cigarettes on a plane. See httr): // www .electronicciaareftereview.com /best - electronic- cigarette U.S. Senator Frank Lautenberg (New Jersey), who spearheaded requiring 100% smokefree airlines, voices his concerns with e- cigarettes. Read the Senator's letter to the FDA at httr): / /www.nigasp.org /Eci r_ss release 03 23- 09.odf 8. Products themselves can be unreliable and dangerous. Batteries or other components of e- cigarettes can be dangerous, exploding and causing fires. In December 2013 a fire was started in a Phoenix, Arizona home. Fire officials say the electronic smoking device cartridge overheated while plugged into the charger. httr): / /www.r)igasr).org /ABC 15 ArizonaFireECig 1 1 14.pdf In November 2013, an Idaho house fire was started when an overcharged electronic cigarette exploded. httr): / /www.rj�gasr).org /News5 Idaho eciq_housefire 11 -5 -13 In February 2012, a Florida man was seriously injured when his e- cigarette exploded in his mouth, taking out some of his front teeth and part of his tongue, and starting a fire in his home. htto: / /www.njgaso.org /ABCNews ECiQ Explodes 2- 17- 2012.pdf In August 2014, a UK man died when a fire was started due to his e- cigarette. The fire then caused his oxygen system to explode. http: / /www.nigasp.orQ /e- cigarette- kills- man- in -uk- after - exploding- into - flames/ The U.S. Department of Health and Human Services has a webpage to report safety issues with products. Go to: httos : / /www.safetyreporting.hhs. gov/ fpsr/ WorkflowLoginlO .asox ?metinstance= OFD3FD8B7F7C 1 COC 1 BD207 BCB3C4769AC46F 1300 9. Health risks of nicotine 27 Powerful side effects of nicotine on the cardiovascular system: r� Releases epinephrine (adrenaline), which raises blood pressure, heart rate and respiration and glucose levels. ➢ Vasoconstrictor - harder fcr the heart to pump through constricted arteries. May cause body to release stored fat and cholesterol into bloodstream. f t' � '�'�_i � ti ik_i1�eriiCa.Or� eviki flu of ➢ Nicotine itself promotes blood vessel damage by promoting cellular damage in vascular smooth muscle cells, promoting plaque formation thereby causing blood vessel damage. fittr)://www.nigaSD.OrCi Biophysics presents nicotine findings 2- 26- 2012.pdf Nicotine plays multiple roles in carcinogenesis through inhibition of apoptosis and cell proliferation (Catassi et al. 2008; Wright et al. 1993; Zhou et al. 2010). It is known to affect oxidative stress and to have adverse effects on brain and lung development in children (Zhou et al. 2010). Nicotine may have adverse effects on vascular function and might promote inflammation (Wiitebole ei al. 2007). Because nicotine and other THS constituents may be transformed into new toxicants (Sleiman et al. 2010a, 2010b), concerns about potential health risks of THS must include compounds created through secondary reactions. Thirdhand Tobacco Smoke: Emerging Evidence and Arguments for a Multidisciplinary Researc-i Agenda, Environmental Health Perspectives (journal), published May 31, 2011. http: / /ehp03.niehs.nih.gov, /article /fetchArticle. action ?articieURI = info %3Adoi %2FI 0.1289% 2Fehp.1103500 ➢ Nicotine and the increased cholinergic activity it causes have been shown to impede apoptosis, which is one of --he methods by which the body destroys unwanted cells (programmed cell death). Since apoptosis helps to remove mutated or damaged cells that may eventually become cancerous, the inhibitory actions of nicotine may create a more favorable environment for cancer to develop. f)tto: / /en.wikipedio.org /wiki /Nicotine Nicotine raises blood sugar levels and the more nicotine that was present, the higher the blood sugar levels were. Higher blood sugar levels are linked to an increased risk of complications from diabetes, such as eye and kidney disease. Researchers from California State Polytechnic University in Pomona presented the study's findings at the American Chemical Socie 7y meeting in Anaheim, California, March 27, 2010. Author Xiao -Chuan Liu concludec', "This study should encourage diabetics to quit smoking completely, and to realize that it's the nicotine that's raising [blood sugar levels]." http: / /n1gasp.ora/ Yahoo- Ne\,\'s- Nicotine- Raises - Blood- Sugar - Levels- 3 -27 -1 l.odf See also 1989 study, which similarly conc uded that Nicotine increases glucose levels, making blood sugar levels even harder to manage in diabetics. fittp:// findarticles.com /p /arti(.Ies /mi m0689/is n5 v28 /ai 7923099/ r Women who use nicotine chum and patches during the early stages of pregnancy face an increased risk of having babies with birth defects, says a study that looked at about 77,000 pregnant women it Denmark. The study found that women who use nicotine - replacement therapy in the first 12 weeks of pregnancy have a 60 percent greater risk of having babies with birth dE�fects, compared to women who are non - smokers, the Daily Mail reported. The findings were published in the Journal Obstetrics and Gynecology. http: / /en.wikipedia.ora /wiki /t licotine A study from South Africa (it the University of Stellenbosch found that exposure to nicotine decreased the overall viability of sperm by between 5 and 15 percent. 28 http: / /www.n*Qasio.ora /IOL Male fertility study 9- 12- 12.pdf ➢ There are documented cases of tobacco workers suffering from nicotine overdose as a result of handling raw tobacco leaves, a condition known as Green Tobacco Sickness. htto: / /www.enotes.com/ how - products - encyclopedia /nicotine -patch httr): / /en.wikipedia.org /wiki /Green Tobacco_ Sickness Spilling an extremely high concentration of nicotine onto the skin can result in intoxication or even death since nicotine readily passes into the bloodstream from dermal contact. Lockhart LP (1933). "Nicotine poisoning ". Br Med J 1: 246 -7 ➢ In some cases children have become poisoned by topical medicinal creams which contain nicotine. http: / /en.wikipedia.orcl/wiki /Nicotine poisoning Nicotine is FDA - regulated in NRTs, but not for e- cigarettes. Nicotine replacement therapy treatments (NRTs), such as the patch, gum, nasal spray, lozenges, are made with pharmaceutical grade nicotine. Manufacturers of FDA - approved nicotine replacement products are required to submit a detailed Manufacturing and Controls Section as part of the New Drug Application (NDA). This documentation assures that the product is manufactured in compliance with Good Manufacturing Practices regulations. The NDA includes sourcing, processing and meticulous documentation at each step of production and use of a pharmaceutical grade active drug. These rigorous conditions are required to assure that the product contains the type and quantity of the drug as labeled. Failure of a manufacturer of an NDA product to comply with these regulations can result in prosecution / enforcement action by the FDA for marketing an adulterated, mislabeled and /or illegal drug product under U. S. law. The FDA does not regulate nicotine products used with e- cigarettes for quality or quantity. The FDA's preliminary analysis showed that levels of nicotine can vary per tested cartridge, regardless of labeling, and that nicotine was found in nicotine -free labeled product. 10. E- cigarettes are drug delivery devices; therapeutic claims may require FDA approval. The FDA classifies nicotine as a drug. E- cigarettes deliver nicotine to the user, like other nicotine delivery devices that are FDA approved as smoking cessation products (e.g. nicotine patch, lozenge, nasal inhaler, etc.) On September 8, 2010, the FDA issued letters stating that electronic cigarettes and similar products meet the definition of drug delivery devices and need to be regulated as such. See Section 1 1 on page 7 of this white paper, for more details on the FDA's September 8, 2010 letters. The July 2009 FDA study found different e- cigarettes yielded different levels of nicotine dosages, with one delivering approximately twice the amount allowable from an FDA approved nicotine nasal inhaler that is used for smoking cessation purposes. Nicotine poisoning is a concern. The FDA is required to approve and regulate tobacco cessation products under Federal Food, Drug, and Cosmetic Act (FFDCA) section 505(a) or 21 U.S.C. 355. Tobacco cessation products are considered drugs that have to undergo the new drug application /FDA approval process. httr):// www. fda. gov/ TobaccoProducts /"ResourcesforYou /ucm l 6823l .htm Websites that sell e- cigarettes, and share testimonials from users about how the e- cigarettes helped them reduce smoking cigarettes, may be promoting the product for smoking cessation purposes. Only FDA approved smoking cessation products are allowed to market and sell their product for a smoking cessation purpose. If a product is marketed and sold as a smoking cessation product, without FDA approval, that product should not be sold. W III. FDA Regulation and Litigation 1. FDA decides not to appeal court decision allowing e- cigarette imports to USA April 25, 2011: the FDA announced that it will not appeal the recent decision by the U.S. Court of Appeals for the D.C. Circuit in Sottera, Inc. v. Food & Drug Administration, 627 F.3d 891 (D.C. Cir. 2010), stating that e- cigarettes and other products are not drugs /devices unless they are marketed for therapeutic purposes, but that products "made or derived from tobacco" can be regulated as "tobacco products" under the FD&C Act. The FDA webpage stated that the FDA is aware that certain products made or derived from tobacco, such as electronic cigarettes, are not currently subject to pre- market review requirements of the Family Smoking Prevention and Tobacco Control Act. FDA is devE.�loping a strategy to regulate this emerging class of products as tobacco products under the Family Smoking Prevention and Tobacco Control Act. Products that are marketed for therapeutic purposes will continue to be regulated as drugs and /or devices. The FDA "is considering whether to issue guidance and /or a regulation on 'therapeutic' claims." Sourced directly from FDA website at http: // www. fdo. gov / NewsEvents /Public Heal thFocus /ucm 172906.htm Stakeholder letter: htto: / /www.fda.g v/ NewsEvents/ PublicHealthFocus /ucm252360.htm December 20, 2010: The FDA filed a new appeal, asking the full U.S. Court of Appeals to reinstate a stay of the preliminary Injunction, pending the FDA's request for a rehearing of the case. The FDA argues that the three -judge panel's December 7, 2010 decision "rests on a clear error of law and will undermine" objectives that were laid out by Congress when it passed legislation in 2009 that empowered the FDA to regulate tobacco products for the first time. In early December, the Court of Appeals three -judge panel ruled that e- cigarettes and other products made or derived from tobacco can be regulated as "tobacco products" by the FDA, unless marketers make specific claims that the devices help smokers quit or provide other therapeutic remedies. Wall Street Journal at htto: / /online.ws'.com /article /SB 10001. 424052748703581204576033640017829896 .htnil The three -judge panel decision on December 7, 2010 affirmed the District Court's preliminary injunction that allows NJOY to import their e- cigarettes while the lawsuit is pending. The Court of Appeals noted that the factual record on NJOY is "meager ", and intimated that the FDA should consider trying to establish that N_10Y does in fact make therapeutic claims regarding its electronic cigarettes. www.niaaso.org/SotteravFDADCCourtof6opealsDeci5iorL.pdf, pg. 13 If the FDA is successful in its claim that NJOY makes therapeutic claims, then the FDA may have jurisdiction over NJOY's e- cigarette products under the FDCA's drug /device provisions. Some e- cigarette companies market their products as smoking cessation devices, as evidenced on their website testimonials, at live demos, etc. September 8, 2010: The FDA issued warning letters to five electronic cigarette distributors for various violations of the Federal Food, Drug, and Cosmetic Act (FDCA) including unsubstantiated claims and poor manufacturing practices. In letters to the Electronic Cigarette Association and the five distributors, the FDA said the agency intends to regulate electronic cigarette and related products in a manner consistent with its mission of protecting the public health. The FDA determined that the electronic cigarette products addressed in the warning letters, and similar products, meet the definitions of both a drug and device under the Federal Food, Drug and Cosmetic Act, and the definition of a combination product in 21 C.F.R. Part 3, with a drug primary mode of action. Firms that introduce these electronic cigarette products into the marketplace will have to comply with the FDCA, including the drug approval process. http: / /www.fdo.aov/ NewsEvents / Newsroom /PressAnnOUf )cements /Ucrn225224.htm htto: / /www.fda.aov/ downloads/ Drucis/ GuidanceComr)lianceReaulatorvinformation /UCM225263.odf The 5 e- cigarette companies have 15 days from Sept 8, 2010 (date of FDA notices of violations) to describe steps each will take to rectify the violations. If the FDA does not receive sufficient 30 responses from each company, the FDA may seek seizure of the e- cigarette products, and injunctive relief. May 24, 2010: The FDA filed its appellate brief for the pending lawsuit being heard by the District of Columbia Court of Appeals, in its e- cigarettes lawsuit, and national tobacco control organizations filed an amicus brief on behalf of the FDA's case which can be read at http: / /www.cosaa.org /files /FDA Appeals Brief.odf. Court papers on this appeal due by July 22, 2010. April 2, 2010: The U.S. Court of Appeals (District of Columbia) ruled that the FDA can ban the importation of e- cigarettes into the USA, during the pending of a lawsuit filed by the e- cigarette company plaintiffs. The U.S. Court of Appeals reversed a lower court decision that disallowed the FDA from banning the importation of e- cigarettes while the litigation proceeded. This April 2, 2010 ruling is a win for the FDA. Read the April 2, 2010 U.S. Court of Appeals decision at htto: / /www.ash.org /eciQstay. Read the April 21, 2010 newsclip on our website http : / /www.nyaasr).org /e- cigs -fda- ban -04- 2010- article.odf. March 1, 2009, U.S. FDA: FDA opened an investigation, refusing to allow e- cigarettes, e- cigars and e -pipes to cross the border on a case -by -case basis. The FDA concludes that e- cigarettes meet the definition of a combination drug device product under the Federal Food, Drug and Cosmetic Act, considers e- cigarettes new drugs that require FDA approval: The U.S. Food and Drug Administration has reviewed several electronic cigarettes, cigars, and pipes, and refused these products at the United States border. The agency has acted because these products offered for import appear to require FDA approval to be legally marketed in the U.S and have not been reviewed by the agency. These products consist of devices that turn nicotine and other chemicals into a vapor to be inhaled by the user. They are typically designed to look like conventional cigarettes, cigars, and pipes, and to be used the same way. The FDA is concerned about the potential for addiction to and abuse of these products. They may also be perceived as safer alternatives to conventional tobacco use and possibly initiate nicotine use among those who have never smoked, or among former smokers. The agency is also concerned that this could lead to an increase in the use of conventional tobacco products by young people, with well -known adverse health consequences. As of March 1, 2009, the FDA had refused 17 shipments of various brands of these "electronic" cigarettes, cigars, and pipes, and their components. At that time, the FDA stated it would continue to evaluate these products on a case -by -case basis. See FDA statement for full details. httr-)://cfc.w'la.com/exterr)al.cfm?r)=fdaecias033109 2. Transcript highlights from FDA's July 2009 media call re: preliminary analysis Several leading experts provided information on the FDA's media call in July 2009, to discuss the FDA's findings in their preliminary analysis of a sampling of e- cigarettes: Dr. Jonathan Samet, Director of the Institute for Global Health at the University of Southern California, is a leading authority on the health effects of smoking and air pollution and he serves as Consulting Editor and Senior Scientific Editor for the Surgeon General Reports on smoking and health including the 1985, 1986, 1990, 2004 and 2006 reports. Dr. Samet commented on the study, stating that: ➢ "... one group of compounds were the tobacco specific nitrosoamines which are quite closely linked in smokers to lung cancer and they were found in detectible - they were detected." (page 19) 31 Mr. Westenberger is the Deputy Director at the Center for Drug Evaluation and Research at FDA in the Division of Pharmaceutical Analysis. He has served with FDA for 39 years. The CIDER is where the FDA's preliminary testing was conducted on electronic cigarettes. Testing was performed by a team of analytical chemists under his supervision and he wrote the final report. On the media call, Mr. Westenberger stated the following: "... the majority of the samples tested positive for the presence of tobacco specific impurities suspected of being harmful to humans such as anabasine, myosmine, and beta- nicotyrine." (page 4) "... Half the samples also tested positive for the presence of certain tobacco specific nitrosoamines that are known human carcinogens such as N- (nitrosonornicotine), and 4- (m ethyl nitrosoamino) -1 -(3- pyridyl)- 1- butanone. In addition to these carcinogenic impurities one cartridge was found to have approximately I% diethylene glycol present a toxic compound to humans. As for as the manufacturing quality some of the cartridges listed as containing no nicotine were actually found to have nicotine present." (page 4) ➢ " ... Variability in the amount of nicotine delivered is also an issue. Three different cartridges with the same label contained significantly different amounts of nicotine per puff ranging anywhere from 27 to 43 micrograms. All of these results indicate a lack of general overall quality control. In summary these results suggest e- cigarettes could have safety and quality concerns. "(page 4) Dr. Jonathan Winickoff is a practicing Pediatrician and Assistant Professor of Pediatrics at Harvard Medical School and the Chair of the American Academy of Pediatrics Tobacco Consortium. "... electronic cigarettes are available on the market in a variety of flavors such as bubblegum, chocolate and mint. Past experience suggests that these products may be particularly appealing to young people." (page 7) y Flavored regular cigarettes promote youth initiation and help young occasional smokers to become daily smokers. Similarly e- cigarettes might encourage children, teens and young adults to take their first step toward smoking cigarettes. Young people may be attracted to these products due to their novelty, safety claims and the availability of the products in a variety of fruit, candy, cola and chocolate flavors. In addition these products are easily accessed online, in stores and at mall kiosks where young people often hang out. (page 7) One cigarette company is claimed to be putting vitamins in the cartridges. This is either a direct or an implied health claim that may confuse some potential users into thinking that the product promotes health when it actually might lead to nicotine dependence. The advertising warning that "this product is for adults only" appears tailor made to appeal to kids. (page 7) ,> Nicotine addiction is one of the hardest addictions to break. An expanding pool of unregulated nicotine products that appeal to youth might increase the overall number of individuals who become nicotine dependent for life and later use regular cigarettes. (page 8) Once you've smoked the e- cigarette and are nicotine dependent the leap to a regular cigarette may not seem as great. Between 1/3 and 1/2 of all youth who try a regular cigarette will become daily smokers because of the highly addictive nature of nicotine. It is therefore vital to decrease exposure to products that would lead to experimentation with nicotine. It is not a safe drug to try. (page 8) 32 ➢ My last point is that nicotine can be toxic in higher amounts for adults but it takes much less to have toxic effects in children. It is unclear what safety mechanisms are in place for these devices. For example, a young child modeling a parent might be able to inhale the entire nicotine load of an e- cigarette cartridge simply by puffing until it was empty. (page 8) httr): / /www.fdo.Qov/ downloads /NewsEvents /Newsroom /MediaTranscripts /UCM 173405.odf IV. New Jersey Nuisance Code NJSA 26:3 -46. Abatement of nuisances The local board, within its jurisdiction, shall examine into and prohibit any nuisance, offensive matter, foul or noxious odors, gases or vapors, water in which mosquito larvae breed, and all causes of disease which may be known to the board or brought to its attention, which, in its opinion, are injurious to the health of the inhabitants therein, and shall cause the same to be removed and abated at the expense of the owner. NJSA 26:3 -47. Abatement without ordinance The power given to the local board to remove and abate nuisances, sources of foulness, or causes of sickness hazardous to the public health, shall not depend upon whether the board has exercised its power to pass, alter, or amend ordinances in relation to the public health. NJSA 26:3 -48. Nuisance on public property; notice Whenever a nuisance, noxious odors, gases or vapors, water in which mosquito larvae breed, or cause of ill health or disease is found on public property or on a highway, notice shall be given by the local board to the person officially in charge thereof to remove and abate the same within such time as the board may specify. If he fails to comply with the notice, the mode of procedure shall be the same as is hereinafter provided in case of a like condition existing on private property. NJSA 26:3 -49. Nuisance on private property; notice Whenever any nuisance, noxious gases or vapors, water in which mosquito larvae breed, or cause of ill health or disease is found on private property, the local board shall notify the owner to remove and abate the same, at his own expense, within such time as the board may specify. A duplicate of the notice shall be left with one or more of the tenants or occupants. If the owner resides out of the state or cannot be so notified speedily, a notice left at the house or premises with the tenant or occupant, or posted on the premises, shall suffice. NJSA 26:3 -50. Failure to comply with notice; abatement If the owner when notified, as provided in section 26:3 -49 of this title, shall not comply with the notice or order of the local board within the time specified, the board shall proceed to abate the nuisance and remove the cause of such foul or noxious odors, gases or vapors, water in which mosquito larvae breed, or other thing detrimental to the public health. 33 POISON He kP 1 -80.0 -222 -1222 AAPCC American Association of Poison Control Centers For Immediate Release July 11, 2014 NEWS RELEASE For More Information, Contact: Brett Schuster, Associate Manager, Public Relations and Government Affairs schuster(a),aapcc.org; 703 - 894 -1859 AAPCC Issues Statement on the Introduction of the Child Nicotine Poison Prevention Act of 2014 ALEXANDRIA, VA — The American Association of Poison Control Centers and the experts at America's 55 poison centers are commending Senator Bill Nelson (D -FL) for his introduction of the Child Nicotine Poison Prevention Act of 2014 on July 10, 2014. Along with fellow Senate co- sponsors, this bill urges the U.S. Consumer Products Safety Commission (CPSC) to enact rules requiring safer, child - resistant packaging for any liquid nicotine sold to consumers. Senate co- sponsors of the bill include: Sen. Richard Blumenthal (D -CT), Sen. Barbara Boxer (D -CA), Sen. Sherrod Brown (D -OH), Sen. Dick Durbin (D -IL), Sen. Tom Harkin (D -IA), Sen. Ed Markey (D- MA), Sen. Jeff Merkley (D -OR), Sen. Mark Pryor (D -AR) and Sen. Charles Schumer (D -NY). "I am introducing the Child Nicotine Poisoning Prevention Act... to prevent these unnecessary tragedies," said Sen. Nelson during his bill introduction, and calling this "common -sense legislation." Speaking at a press conference in Tampa, Fla., on Friday, July 11, Sen. Nelson questioned, "If we childproof other medicines, like (acetaminophen) and aspirin, why in the world wouldn't we do this ?" Sen. Nelson concluded his Senate floor statements by requesting "unanimous consent that these remarks and the Child Nicotine Poisoning Prevention Act of 2014 be printed in the Congressional Record." Also speaking at the press conference was Dr. Fred Aleguas, PharmD, DABAT, director of the Florida Poison Information Center — Tampa, who stated, "Poison Centers have had these e- cigarette products on their radar for a couple of years and have been investigating the concentration (levels) of nicotine products and found that the percentages were off by up to 50 percent. There is zero regulation for nicotine concentration." — more — 515 King Street, Suite 510, Alexandria, Virginia 22314 703 - 894 -1858 www.aapcc.org Dr. Aleguas continued, "It's an important initiative to make these products child- resistant. The brightly colored- bottles, fruit flavors and the devices themselves are attractive to children and we have no idea what effects some of the ingredients will cause." "Our network of 55 poison centers is in a unique position to detect emerging public health threats, such as that posed by e- cigarettes and liquid nicotine," said AAPCC President Dr. Marsha Ford, MD, FACMT, FACEP. "Data about every call made to a poison center are uploaded every nine minutes to the National Poison Data System. This near real -time data collection provides the AAPCC and poison centers across the country the ability to detect new threats and quickly notify appropriate authorities at the local, state and federal levels. Once a threat is detected, the poison center network is a vital partner in local, state and federal response efforts." On April 30, 2014, Vermont lawmakers approved an amendment to State Senate bill S. 239 requiring child -proof packaging on liquid nicotine containers. Effective Jan. 1, 2015, Minnesota will become the second state to adopt similar legislation as Minnesota Statute 461.20 goes into effect. For more information, the media may contact Brett Schuster, AAPCC Associate Manager, Public Relations and Government Affairs, at 703.894.1859 or schuster(a),aapcc.org. The AAPCC supports the nation's 55 poison center members in their efforts to treat and prevent drug, consumer product, animal, environmental and food poisoning. Members staff the Poison Help hotline at 1- 800 - 222 -1222 that provides free, confidential, expert medical advice 24 hours a day, seven days a week, 365 days a year from toxicology specialists, including nurses, pharmacists, physicians and poison information providers. In addition, the AAPCC maintains the onlypoison information and surveillance database in the United States, providing real -time monitoring of unusual poisoning patterns, chemical exposures and other emerging public health hazards. The AAPCC partners with federal agencies such as EPA, HRSA and the CDC, as well as private industry. To learn more, visit it it-w.aapcc.org, like us on Facebook, follow its on Twitter, or read our blog at acrpcc. wordpress. com. To join your voice with other poison center supporters, register for the AAPCC advocacy network at wivtiv.capwiz.conr / aapcc — click on "Action E -List. " —30— 515 King Street, Suite 510, Alexandria, Virginia 22314 703 - 894 -1858 www.aapcc.org N_AC_C_H,0 National Association of County & City Health officials The National Connection for Local Public Health 12 -04 STATEMENT OF POLICY Regulation of Electronic Cigarettes ( "E- Cigarettes ") Policy The National Association of County and City Health Officials ( NACCHO) urges the Food and Drug Administration (FDA) to enact strict regulations overseeing the sale, manufacture, distribution, and advertising of electronic cigarettes, or e- cigarettes, and to conduct research on their health impact. Until then, NACCHO encourages local health departments to support local legislation and regulations that include any or all of the following measures: 1,2 • Use broadly - defined language to include e- cigarettes in new smoke -free legislation for indoor and outdoor environments. • Make clear that e- cigarettes are covered by existing smoke -free laws through clarifying opinion or regulation/rule. (Opening up or amending the definitions of "smoke" and "smoking" to include e- cigarettes and e- cigarette vapor or aerosol may jeopardize existing laws.) • Require tobacco retailer licenses to sell e- cigarettes, or add an additional fee for existing tobacco retailers to sell e- cigarettes. • Limit the number of retailers or locations where e- cigarettes can be sold. • Prohibit sales of e- cigarettes to minors. • Ban sales of e- cigarette components that may appeal to minors, such as flavored cartridges. Raise excise tax on e- cigarettes to a level equivalent to cigarettes and other tobacco products. • Require disclosure of the chemicals included in electronic cigarette cartridges. NACCHO also encourages local health departments to support e- cigarette control policy efforts through any or all of the following: • Oppose legislation at the local or state level that exempts e- cigarettes from current smoking ban policies and regulations. • Advocate for state or federal regulation prohibiting sales of e- cigarettes on the Internet or through the mail, especially in the case of minors. • Work with businesses and public institutions, such as malls, to voluntarily prohibit e- cigarette sales on premises. Justification In April 2011, the FDA announced that it intends to develop regulations for e- cigarettes. 3 E- cigarettes are battery- operated products designed to deliver nicotine, flavor, or other chemicals through a vapor or aerosol inhaled by the user.4 Most e- cigarettes are manufactured to resemble FN cHealth 1100 170 ° S':u t 1,M, .`_t.'vt. :'t f n)JI ..dtih' city" I)„ �(�t)jF) � Ili)�1 j t� Cpl' F {;10 :1) I,)';3 www.naccho.org Pre t. Promote. Protect. cigarettes, cigars, and pipes' often with an LED light at the tip that mimics the glow of a conventional cigarette.6 Between 2010 and 2011, the proportion of e- cigarette ever -users doubled to 6.2% of all adults and 21.2% of -,urrent smokers. NACCHO recognizes the importance of finding additional tools to help smokers quit. Currently, little scientific evidence exists to show that e- cigarettes are effective cessation devices. Furthermore, in 2010, a federal court ruling blocked the FDA's attempts to broadly regulate e- cigarettes as drugs or drug delivery devices. However, the FDA can still regulate e- cigarettes, similar to regulations for nicotine r .-placement therapy, if therapeutic claims are made.8 Until further research shows that they are safe and effective as a cessation product, NACCHO suggests that e- cigarettes are regulated to the extent that the law allows for tobacco products. To that end, the FDA has the authority to regulate e- cigarettes as tobacco products under the Family Smoking Prevention and Tobacco Control Act even though the FDA has yet to exert that authority. According to the provisions of the Act, state and local governments can take additional steps to regulate the sale and use of tobacco products and enact measures that are more restrictive than federal law.9 Further research is needed on the health risks of e- cigarettes, but available evidence suggests harmful effects. A recent study published in the European Respiratory Journal found that e- cigarette users get as much nicotine from e- cigarettes as smokers usually get from tobacco cigarettes.10 The FDA warns users of the potential health risks posed by e- cigarettes.' 1, 12 In addition to nicotine, an FDA laboratory analysis found that e- cigarettes contain carcinogens and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze. Because there is little control or regulation of e- cigarette products, the amount of nicotine inhaled with each "puff' may vary substantially, and testing of sample cartridges found that some labeled as nicotine -free in fact had low levels of nicotine." Users can refill their own cartridges with much higher doses of nicotine, and the devices can also be filled with other harmful substances. For example, instructions for filling cartridges with marijuana hash oil can be easily accessed on the Internet." The use of e- cigarettes makes it difficult for business owners and officials to enforce existing smoke -free air laws." Their close resemblance to conventional cigarettes may cause confusion and lead people to believe that it is legal to smoke in smoke -free environments. Additionally, some e- cigarettes designed to look like everyday items, such as pens and USB memory sticks 16 make it easy for youth to disguise these products in schools and other settings. Prevalence of e- cigarettes in public places increases second -hand exposure to the harmful chemicals released from this product. Exhaled e- cigarette vapor or aerosol contains toxins and carcinogens, such as nicotine, formaldehyde, and acetal Jehyde that are released into the air. The health impact of this exposure is a large concern and needs further investigation. 17 Public health experts have expressed concern that e- cigarettes may increase nicotine addiction and tobacco use in young people. "I E- cigarettes may be particularly appealing to youth due to their high -tech design, wide array of available flavors, including candy- and fruit - flavored cartridges, and easy availability online and in shopping malls.19 Because in nearly all jurisdictions they are not taxed as tobacco products, e- cigarettes may be more easily obtained by price- sensitive youth. A 2013 Morbidity and Mortality Weekly Report released by the Centers for Disease Control and Prevention found that e- cigarette use more than doubled among U.S. middle and high school students from 2011 - 2012.20 The report also noted that 20% of middle school e- cigarette users reported never having smoked conventional cigarettes.21 There is strong public support for regulation of e- cigarettes, according to the University of Michigan C.S. Mott Children's Hospital National Poll on Children's Health. Among the findings, 85 percent of U.S. adults favored prohibiting the sale of e- cigarettes to minors, and 91 percent supported requiring manufacturers to test e- cigarettes for safety. 22 Various federal, state, and local regulations are in place or are being considered to restrict e- cigarette use and sales. Amtrak has banned the use of electronic smoking devices, such as e- cigarettes, on trains, in stations, and in any area where smoking is prohibited.23 In a memorandum, the Air Force Surgeon General warned about safety concerns regarding electronic cigarettes and placed them in the same category as tobacco products. 21 Currently, the U.S. Department of Transportation is proposing a regulation that would ban the use of e- cigarettes on aircraft by clarifying that the use of e- cigarettes is prohibited in the same way that the use of tobacco products is prohibited .21 Several state and local governments have taken steps to limit e- cigarette use in public places and prohibit the sale of e- cigarettes to minors. 26 References 1. Tobacco Control Legal Consortium. (2013). Regulating Electronic Cigarettes and Similar Devices. Retrieved on March 31, 2014 from http• / /publichealthlawcenter org /topics/ tobacco - control /product- regulation/e- cigarettes 2. American Cancer Society Cancer Action Network, American Heart Association, American Lung Association, and the Campaign for Tobacco -Free Kids. (2011). Policy Guidance Document Regarding E- Cigarettes. Retrieved on November 13, 2011 from http://iiaquitline.site- ym.com/resource/resmgr/news/Revised Policy Guidance on E.pdf. 3. Denton, L. and Woodcock, J. (2011). Regulation of e- cigarettes and other tobacco products. Retrieved on April 6, 2014 from http://www.fda.jzov/newsevents/publichealthfocus/ucm252360.htm . 4. U.S. Food and Drug Administration. (2011). Electronic Cigarettes. Retrieved on November 13, 2011 from http/ /www fda gov /newsevents/ publichealthfocus /ucml72906.htm. 5. Ibid. 6. ChangeLab Solutions. (2011). Electronic Cigarettes: How They Are - and Could Be - Regulated. Retrieved on April 6, 2014 from http• / /changelabsolutions.org /sites /default /files /E- cigarette FactSht FINAL %28CLS 20120530 %29 October2l 2011 O.pdf . 7. King, B.A., Alam S., Promoff G., Arrazola R., Dube S.R. (2013) Awareness and ever -use of electronic cigarettes among U.S. adults, 2010 -2011. Nicotine Tob Res. Voll5(9):1623 -1627. 8. Tobacco Control Legal Consortium. (2013). Regulating Electronic Cigarettes and Similar Devices. Retrieved on March 31, 2014 from http• / /publiciiealthlawcenter orp/topics/ tobacco - control /product- regulation/e- cigarettes 9. Ibid. 10. Etter, J.F. and Bullen, C. (2011) Saliva cotinine levels in users of electronic cigarettes. European Respiratory Journal. Vol 38, 1219 -1220. 11. U.S. Food and Drug Administration. (2011). Electronic Cigarettes. Retrieved on November 13, 2011 from http://www.fda.gov/newsevents/publichealthfocus/ucml72906.htm. 12. U.S. Food and Drug Administration. (2009). FDA and Public Health Experts Warn About Electronic Cigarettes. Retrieved on November 13, 2011 from http/ /www fda gov/NewsEvents[ Newsroom/ PressAnnouncements /ucm173222.htm. 13. Ibid. 14. American Legacy Foundation. (2011). E- Cigarette or Drug Delivery Device ?: Schroeder Institute Researchers Raise Questions About Safety, Usage and Future Implications of New Nicotine Delivery Products. Retrieved on November 11, 2011 from htti2://www.le.pacyforhealth.org/4550.aspx. 15. American Cancer Society Cancer Action Network, American Heart Association, American Lung Association, and the Campaign for Tobacco -Free Kids. (2011). Policy Guidance Document Regarding E- Cigarettes. Retrieved on November 13, 2011 from http://naguitline.site- ym.com /resourcefresingr /news /Revised Policy Guidance on E.pdf. 16. U.S. Food and Drug Administration. (2011). Electronic Cigarettes. Retrieved on November 13, 2011 from http://www.fda.jzov/newsevents/12ubl ichealthfocus/ucml 72906.htm. 17. Schripp, T., Markeqitz, D., Uhde, E. and Salthammer, T. (2012). Does e- cigarette consumption cause passive vaping? Indoor Air, 23(1); 25 -31. 18. U.S. Food and Drug Administration. (2009). FDA and Public Health Experts Warn About Electronic Cigarettes. Retrieved on November 13, 2011 from http: / /www.fda. gov/News Events / Newsroom /PressAnnouncements /ucin l 73222.htm. 19. American Legacy Foundation. (2009). Electronic Cigarettes ( "E- cigarettes'). Retrieved on November 12, 2011 from http: // www. legacyforhealth .org(PDFPublications[ECIGARETTE 0909 temp.pdf. 20. Centers for Disease Control and Prevention. Notes from the field: Electronic cigarette use among middle and high school students — United States, 2011 -2012. MMWR 2013; 62, 729 -730. Retrieved on April 16, 2014 from http://www.cdc.gov/mmwr/preview/inmwrhtml/mm6235a6.htm. 21. Ibid. 22. University of Michigan Health System. (2010). e- Cigarettes: Support strong for health warnings, banning sales to minors. Retrieved on November 11, 2011 from http: / /www2.med.umich.edu /prmc /media/newsroom /details.cfm ?ID =171 1. 23. Amtrak. Smoking and Non- Smoking,policies. (2011). Retrieved on November 11, 2011 http: // www. amtrak. com /servlet /C,ontintServer ?c= Page &paagename= ani %2FLayout &cid= 1241267382715 24. U.S. Air Force. AF surgeon general issues warning about safety of electronic cigarettes. (2010). Retrieved on November 11, 2011 http: / /www.afmil /news /story.asp ?id= 123218666. 25. U.S. Department of Transportation. US. Department of Transportation Proposes to Ban the Use of Electronic Cigarettes on Aircraft. (2011). Retrieved on November 11, 2011 http: / /www.dot.gov /affairs /2011 /dot] 1911.html. 26. Tobacco Control Legal Consortium. '2013). Regulating Electronic Cigarettes and Similar Devices. Retrieved on March 31, 2014 from http : //public healthlawcenter.org/ topics/ tobacco - control /product- regulation/e- cigarettes Record of Action Submitted by Community Health Committee Approved by NACCHO Board of Directors March 2012 Updated April 2014 State Story- _�. ---- stho Hawaii Restricts E- Cigarette Sales to Youth The Hawaii State Department of Health helps implement a new law banning the sale of e- cigarettes to minors. In recent years, Hawaii has seen the number of kiosks and vendors selling electronic cigarettes (e- cigarettes) in Hawaii malls proliferate. Some of these kiosks were reportedly seen offering the products to youth. Results from Hawaii's 2011 Youth Tobacco Survey found that 5.1 percent of high school students in Hawaii had used e- cigarettes. After a 2012 effort by Gov. Neil Abercrombie to propose a tax on e- cigarettes failed, Hawaii focused its attention on as bill restricting youth access to e- cigarettes. Supporting the Hawaii State Department of Health (HI DOH) were the state attorney general's office, the Hawaii Department of Education (HI DOE), tobacco control coalitions, and community partners, who worked collaboratively to pass the bill. The legislation not only restricted the sale of e- cigarettes to persons over 18 years of age, but also eliminated all self- service displays of tobacco products. Steps Taken: • In 2013, the governor's administrative package included proposed legislation to create a legal definition for electronic smoking devices and prohibit sales to persons under 18 years of age. • The Coalition for a Tobacco -Free Hawaii (CTFH) and HI DOH conducted a statewide opinion poll among adult voters that included questions regarding the restriction of e- cigarette sales to minors. • The poll results showed a high general awareness of e- cigarettes and strong public opinion in favor of restrictions to minors, with 82% of respondents supporting a ban of e- cigarette sales to those under the age of 18. The demonstration of strong public support helped advance the legislation. • The 2013 administrative proposal recommended that the bill address only sales to minors rather than criminalizing • In 2011, 5.1% of Hawaii high school students had experimented with e- cigarettes. • In 2013, 82% of Hawaiians supported a ban on e- cigarette sales to minors. • Hawaii Revised Statute §709 -908 banned the sale of electronic smoking devices to minors under 18 years of age starting in 2013. e- cigarette possession by minors, since the latter approach reprimands youths —the victims— rather than the distributors who sell e- cigarette products to minors. • HI DOH researched other states' legislation and consulted with the Tobacco Control Legal Consortium to determine the best language to use in the e- cigarette bill. The proposed bill used the term "electronic smoking devices," since this terminology is inclusive of the many forms in which e- cigarettes are manufactured. The bill defines electronic smoking devices as "any electronic product that can be used to simulate smoking in the delivery of nicotine or other substances to the person inhaling from the device, including but not limited to an electronic cigarette, electronic cigar, electronic cigarillo, or electronic pipe, and any cartridge or other component of the device or related product."' © Association of State and Territorial Health Officials 2014 2231 Crystal Drive, Ste 450, Arlington, VA Visit ASTHO's complete story archive at www.astho.org /stories State Story rsth or' • HI DOH and HI DOE informed legislators by providing data on the increasing use of e- cigarettes and youth experimentation. HI DOE had also previously prohibited the possession of e- cigarettes on all public school campuses for students of any age and cited this in testimony to the state legislature in support of the youth sales restriction. • CTFH, using state tobacco settlement funds to support its advocacy efforts, generated action alerts and organized community partners to provide testimony to the state legislature. REAL, an anti- tobacco youth advocacy group, organized considerable youth testimony (written and oral) to support this measure. • During Hawaii's 2013 legislative session, the original administrative bill was deferred. However, the language banning e- cigarette sales to minors was subsequently added to another bill, HB 672, which also focused on restricting access to tobacco products. • HB 672 also included enforcement provisions requiring a sign to be placed at the point of sale for e- cigarette products stating that "the sale of tobacco products or electronic smoking devices to persons under 18 is prohibited . ,,2 • HI DOH convened a task force of police officers, compliance researchers, and CTFH representatives to design the required signage. HI DOH further led an initiative to distribute the new signage for tobacco product retailers using CDC funding. HI DOH mailed the new signs with instructions to the state's list of registered tobacco retailers. • HI DOH developed and placed an advertisement in Hawaii Retail Grocer magazine to promote the new legislation and inform merchants about the requirement for new point -of -sale signage. Results: • The bill amended Hawaii Revised Statute §709 -908 effective July 2013, prohibiting the sale or furnishing of electronic smoking devices to minors under the age of 18. • The bill also required sales of other tobacco products including smokeless tobacco (but not e- cigarettes) to occur through a direct, face -to -face transaction rather than a self- service display.' • The state ban on e- cigarette :sales to minors spurred several localities to also institute stricter regulations. For example, the Island of Hawaii passed a bill in December 2013 that increased the minimum age for sale of tobacco products, including e- cigarettes, from 18 to 21 in the County of Hawaii. • In December 2013, HI DOH created its own internal policy prohibiting the use of e- cigarettes on all premises where its employees work and in HI DOH vehicles throughout the state. This policy went into effect on Jan. 1, 2014. HI DOH also created a draft policy template and signage for other businesses interested in implementing similar policies. • The 2013 and 2015 Hawaii Youth Tobacco Surveys will include more detailed questions about e- cigarettes than the 2011 survey. The survey results will be posted on the Hawaii Health Data Warehouse when they are available. These revised questionnaires will measure the legislation's impact among the diverse youth population of Hawaii. HI DOH and CTFH will conduct a new opinion survey with more questions regarding e- cigarettes. Hawaii has also added new questions regarding e- cigare1:te use to its BRFSS survey. • HI DOH has continued to receive calls from businesses, agencies, restaurants, and bars asking about e- cigarettes and their compliance with indoor smoking laws. In response, the Tobacco Prevention and Education Program provides information and shares its draft policy and signage. © Association of State and Territorial Health Officials 2014 2231 Crystal Drive, Ste 450, Arlington, VA Visit ASTHO's complete story archive at www.astho.org /stories State Story astho"� 12013 House Bill 672, part I, section 2, subsection 5 (Hawaii House of Representatives). Available at http: // www .capitol.hawaii.gov /session20l3 /Bills /HB672 CD1 .HTM. Accessed 5 -8 -2014. z 2013 House Bill 672, part I, section 2, subsection 2 (Hawaii House of Representatives). Available at http: // www .capitol.hawaii.gov /session2Oi3 /Bills /HB672 Wi .HINI. Accessed 5 -8 -2014. 3 2013 House Bill 672, part ll, section 3 (Hawaii House of Representatives). Available at http: // www .capitol.hawaii.gov /session20l3 /Bills /HB672 CD1 .HTM. Accessed 5 -8 -2014. © Association of State and Territorial Health Officials 2014 2231 Crystal Drive, Ste 450, Arlington, VA Visit ASTHO's complete story archive at www.astho.orQ /stories f� State Story as ho- .Afa, Following the success of the 2013 law, several Hawaii legislators proposed new bills in the 2014 legislative session that would include e- cigarettes in the state's clean indoor air laws and require licensure and permits for wholesalers and retailers selling the devices. This proposed legislation did not pass, but the proposed bills would have provided regulatory ability, such as licensing and taxation, and would have removed e- cigarettes' visibility in public spaces and workplaces, which could impact social norms for young people. Lessons Learned: Electronic smoking devices are evolving products and they continue to be marketed in many forms, so use a broad definition when deciding on language for legislation. Don't underestimate e- cigarette manufacturers and the tobacco industry as opponents, and be prepared with good research to refute their lobbying efforts. Manufacturers often deemphasize the potential risks of e- cigarettes to legislators, claiming they are not marketing to youth despite youth - appealing flavors like bubble gum. E- cigarette manufacturers know how to appeal to legislators, and now that most brands have been bought by tobacco companies, they have large marketing and advertising budgets along with national distribution networks to sway public opinion. They have also begun to organize and provide scripts with a small business appeal for local merchants to use to provide testimony to the legislature in opposition of a -cig regulations. There is still a lot to learn about e- cigarettes and how to inform the public about these devices and their components. Since these are emerging products, few states have examples of e- cigarette PSAs or health communications campaigns. The limited amount of scientific data, combined with the lack of existing messaging, makes it difficult for states for develop media campaigns. More formative evaluation is needed to support the development of creative counter - marketing. Show decisionmakers examples of e- cigarette marketing to demonstrate their youth appeal. Legislation on e- cigarettes may move incrementally. Hawaii's successful passage of a ban on sales to youth came after another proposed bill to tax e- cigarettes had been unsuccessful. In 2014, a number of bills were proposed addressing several facets of regulating and taxing e- cigarettes, including new state clean indoor air legislation. Although the process may be long, incremental progress is still important to build support and move toward more comprehensive regulations. For more information: Lila Johnson, RN, MPH, CHES Program Manager Tobacco Prevention and Education Program Hawaii State Department of Health lila.iohnson @doh.hawaii.gov http: / /health.hawaii.gov /tobacco/ Diana Karczmarczyk, PhD, MPH, MCF ES Senior Analyst, Tobacco and Chronic Disease Prevention Association of State and Territorial Health Officials dkarczmarczvk @astho.org © Association of State and Territorial Health Officials 2014 2231 Crystal Drive, Ste 450, Arlington, VA Visit ASTHO's complete story archive at www.astho.org /stories Ni c 8/26/2014 Consumer Updates > E- Cigarettes: Questions and Answers Archived Content The content on this page is provided for reference purposes only. This content has not been altered or updated since it was archived. ''11r Search Archive Home For Consumers Consumer Updates For Consumers E- Cigarettes: Questions and Answers Af a Get Consumer Updates by E -mail' D Consumer Updates RSS Feed Q: What are electronic cigarettes? CA: Electronic cigarettes are products designed to deliver nicotine or other substances to a user in the form of a vapor. Typically, they are composed of a rechargeable, battery- operated heating element, a replaceable cartridge that may contain nicotine or other chemicals, and an atomizer that, when heated, converts the contents of the cartridge into a vapor. This vapor can then be inhaled by the user. These products are often made to look like such products as cigarettes, cigars, and pipes. They are also sometimes made to look like everyday items such as pens and USB memory sticks, for people who wish to use the product without others noticing. Q: What concerns does FDA have regarding electronic cigarettes? A: FDA has not evaluated any e- cigarettes for safety or effectiveness. When FDA conducted limited laboratory studies of certain samples, FDA found significant quality issues that indicate that quality control processes used to manufacture these products are substandard or non- existent. FDA found that cartridges labeled as containing no nicotine contained nicotine and that three different electronic cigarette cartridges with the same label emitted a markedly different amount of nicotine with each puff. Experts have also raised concerns that the marketing of products such as e- cigarettes can increase nicotine addiction amonc_ young people and may lead kids to try other tobacco products. Visit FDA's Electronic Cigarettes webpage3 for additional information Q: What action did FDA take today on electronic cigarettes? A: FDA issued warning letters to five distributors of electronic cigarettes for violations of the Federal Food, Drug, and Cosmetic Act (FDCA). These violations included unsubstantiated claims and poor manufacturing practices. Q: Would it be possible for an electronic cigarette to receive FDA approval? A: Yes. FDA issued a letter to the Electronic Cigarette Association inviting electronic cigarette firms to work in cooperation with the agency toward the goal of assuring that electronic cigarettes sold in the United States are lawfully marketed. The agency intends to regulate electronic cigarettes and related products in a manner consistent with its mission of protecting the public health. hftp://vmw.fda.go\dForConsumers/ConsunierUpdates/ucm22521O.htm 1/3 8/2612014 Con=sumer Updates > E- Cigarettes: Questions and Answers Q: What products should peo who want to quit smoking use? A: There are a number of FDA- approved smoking cessation aids, includiny nicotine gum, nicotine skin patches, nicotine lozenges, nicotine oral inhaled products, and nicotine nasal spray that are available for smokers to use to reduce their dependence on nicotine. Free help is available to all smokers who want to quit at 1- 800 - QUIT -NOW or by visiting www.smokefree.gov4. This article appears on FDA's Consumer Updates pages, which features the latest on all FDA - regulated products. Posted September 9, 2010 back to top For More Information • FDA's Electronic Cigarettes web page6 Related Consumer Updates • FDA Warns of Health Risks Posed by E- Cigarettes [ARCHIVED] • "Light" Tobacco Products Pose Heavy Health Risks8 • What Are You Smoking (or Chewing or Inhaling) ?9 • Less Risky Tobacco Product? Only if the Science Says Solo Page Last Updated: 04/24/2014 Note: If you need help accessing information in different file formats, see Instructions for Downloading Viewers and Players. Accessibility Contact FDA Careers FDA Basics FOIA No Fear Act Site Map Transparency Website Policies U.S. Food and Drug Administration 10903 New Hampshire Avenue Silver Spring, MD 20993 Ph. 1- 888 - INFO -FDA (1 -888- 463 -6332) Email FDA �.g9V tt, fa For Government For Press Combination Products Advisory Committees Science & Research Regulatory Information Safety Emergency Preparedness International Programs News & Events Training and Continuing Education Inspections /Compliance State & Local Officials Consumers Industry Health Professionals FDA Archive U.S. Department of Health & Human Services Links on this page: 1, http: / /service.govdelivery .com /service /subscribe. ht ml ?c ode = USFDA_9 2. /About FDA/ ContactFDA /StayInformed /RSSFeeds /Consumers /rss.xml 3. /News Events /PublicHea IthFocus /ucml72906.htm 4. http: / /www.smokefree.gov 5. /ForConsumers /ConsumerUp<iates /default.htm 6. / NewsEvents/ PublicHeaIthFocus /ucml72906.htm 7. / ForConsumers /ConsumerUpciates /ucml73401.htm x hftp:// www. fda. goVForConsumers /ConsumerUpdates /ucm225210.htm 2/3 0r 4� � rE Dean H. Saki NEIL ABERCROMBIE GOVERNOR ceQptresef �40.D.y,•W�V Marla E. Lellnski camplmner Do" STATE OF HAWAII DEPARTMENT OF ACCOUNTING AND GENERAL SERVICES P 0 BOX 119. HONOLULU HAWAII 96810-0119 September 25, 2014 COMPTROLLER'S MEMORANDUM NO. 2014 -22 TO: Heads of Departments and Agencies Occupying DAGS Buildings ,I, i FROM: Dean H. Seki, Comptroller )Ij SUBJECT: Prohibiting E- Cigarettes in DAGS Buildings Statewide Effective November 16, 2006, Act 295, the Hawaii Smoke -Free Workplace and Public Places Law, prohibited the smoking of tobacco products in places open to the public and places of employment. While the Act did not specifically address the use of electronic cigarettes (e- cigarettes) and other electronic smoking devices, there is a growing concern that the vapors emitted by e- cigarettes may contain harmful elements. Based on various tests that have been conducted, it has been determined that the various samples tested contained not only nicotine, but also detectable levels of known carcinogens and toxic chemicals, including tobacco - specific nitrosamines and diethylene glycol, a toxic chemical used in antifreeze. Prohibiting the use of e- cigarettes in areas where smoking is now prohibited by law will reduce perception on the part of employees and the general public that the use of e- cigarettes is healthy behavior. Furthermore, any negative impact on employee productivity will be diminished by reducing any distractions resulting in the use of e- cigarettes in the workplace. As such, effective October 1, 2014, the Department of Accounting and General Services (DAGS) will prohibit the use of e- cigarettes and other electronic smoking devices in all buildings under its jurisdiction. Areas included in this prohibition shall include, but not be limited to offices, public lobbies, lanais, interior courtyards, patios, covered walkways, and within a minimum distance of twenty (20) feet from entrances, exits, windows that open, and ventilation intakes that serve enclosed or partially enclosed areas where smoking is prohibited. Signage similar to "No Smoking" signs will be posted in appropriate areas to inform users of this policy, which shall apply to the following DAGS buildings: Comptroller's Memorandum No. 2014 -22 September 25, 2014 Page 2 Island of Oahu: 1. State Capitol 12. Kam V Building 2. Kalanimoku Building 13. O R & L Building 3. Liliuokalani Building 14. Central Services Base Yard 4. Kinau Hale 15. Surplus Properties 5. Leiopapa a Kamehameha Building 16. Archives Records Center 6. No. 1 Capitol District Building 17. Kaneohe Civic Center 7. Keoni Ana Building 18. Wahiawa Civic Center 8. Kekauluohi Building 19. Waipahu Civic Center 9. Hale Auhau Building 20. Kakuhihewa Building 10. Kekuanaoa Building 21. King Kalakaua Building 11. Keelikolani Building 22. Washington Place Museum Island of Kauai: 1. Lihue State Office Building 5. DAGS Puhi Office Building 2. Lihue Health Center 6. DAGS Puhi Maintenance Building 3. Lihue Health Center Annex 7. Plant Industry Building 4. Lihue Courthouse 8. Vector Control Building Island of Maui: 1. Kahului Civic Center 2. DAGS Facility, Mua Sireet 3. Wailuku State Office Building Island of Hawaii: 4. Wailuku State Office Building No. 2 5. Kaunakakai State Office Building 1. Hilo State Office Building 8. Honokaa State Office Building No. 1 2. DAGS Hilo Maintenance Facility 9. Honokaa State Office Building No. 2 3. Kona State Office Building No. 1 10. DAGS Honokaa Maintenance Facility 4. Kona State Office Building No. 2 11. Keakealani Office Building 5. Kona State Office Building No. 3 12. Kohala State Office Building 6. DAGS Kona Maintena ice Facility 13. Naalehu State Office Building 7. DAGS Ka'u Maintenance Facility 14. Waimea State Office Building If you have any questions, on Oahu, call James Hisano, Central Services Manager at 831 -6734; on the Island of Hawaii, call Jerry Watanabe, District Engineer at 974 -6400; on Kauai, call Eric Agena, District Engineer at 274 -3030; and on Maui, call Wade Shimabukuro, District Engineer at 877 -3305. 00 American American Heart I Stroke Association Association life is why, October 14, 2014 Testimony in SUPPORT of Bi11302 "Relating To Prohibition of Smoking in Certain Places and the Use of Electronic Smoking Devices" The American Heart Association strongly supports Bill 302, "Relating To Prohibition of Smoking in Certain Places and the Use of Electronic Smoking Devices." For decades, advocacy for tobacco control has been a priority of the American Heart Association (AHA). In partnership with major public health organizations, the association has made major strides in tobacco use prevention and cessation by prioritizing evidence - based strategies such as increasing excise taxes; passing comprehensive smoke -free air laws; facilitating US Food and Drug Administration (FDA) authority to regulate tobacco, including comprehensive tobacco cessation treatment within healthcare plans; and supporting adequate funding of comprehensive tobacco control programs in different states. These tobacco control efforts have cut in half the youth smoking rate from 1997 to 2007 and have saved more than 8 million lives in the past 50 years. Secondhand exposure to e- cigarette aerosol exposes a nonsmoker to nicotine, particulates, and several potentially toxic organic chemicals, but at much lower levels than from conventional cigarette smoke. The biological effects of such an exposure are expected to be much less than that of secondhand smoke, but nonsmokers are exposed to some nicotine, and the regular use of e- cigarettes has the potential to substantially contaminate the environment with nicotine. Moreover, unregulated e- cigarette use has the potential to recreate a social norm around tobacco product use in public places, unraveling decades of work on comprehensive smoke -free air-Jaws. It is not always easy to identify that a person is using an e- cigarette, because there is not the large plume of smoke or the strong detectable odor that comes from conventional cigarettes. Therefore, the use of e- cigarettes creates enforcement issues for employees in restaurants, bars, airport terminals, planes, and other smoke -free public places. E- cigarette companies are marketing their products to be used in all the places where smoking is banned, including bars, restaurants, hotels, offices, and airplanes, which promotes unregulated use. Although the AHA supports the inclusion of e- cigarettes in new smoke -free laws, the AHA only supports changing existing smoke -free laws to include e- cigarettes when it can be ensured there will be no amendments attached to the legislation that would weaken existing laws. S Quilding healthier lives, tree of cardiovascular life is why es por la vida % a� diseases and stroke. " American American Heart ( Stroke Association Association life is why Hawaii County Councilmembers are encouraged to support Bill 302 without substantial amendment to help reduce the exposure of e- cigarette particulate- and nicotine -laced aerosol by non - users, and to continue to denormalize sociatally nicotine addiction. Donald B. Weisman Hawaii Government Relations Director `Building healthier lives: free of cardiovascular life is why es por la vida p�(7 diseases and stroke. " BBB!/ i bbb orb. -ba•i[y Oahu 810 Richards St Suite 750 Honolulu, HI 96813 Tel: (808) 537 -5966 Fax: (808) 537 -5971 www.ala - hawaii.org Executive Director Kim Nguyen, MSW Chair Steve Wilson Leadership Council Steven Businger, Ph.D. Eric Crawley, MD Pebbles Fagan, MD Cathy Foy -Mahi Jeffrey Kam, MD Von Kaneshiro May Kealoha K (Karen) Latzka Ron Sanderson, DrPH James Wong, Esq. Douglas Q.L. Yee Regional Council Sterling Yee President & CEO Renee Klein Lung HelpLine 1 -800- LUNG -USA (586 -4872) Fighting for Air AMERICAN LUNG ASSOCIATION October 13, 2014 IN HAWAII To: Hawaii County Council Committee Chair Honorable Brenda Ford Committee Members, Public Safety Re: Strong Support for Bill 302, Relating to Electronic Smoking Devices Thank you for the opportunity to submit testimony in strong support of Bill 302 for its hearing on October 14. 1 serve as the Executive Director for the American Lung Association in Hawaii, one of six states within the American Lung Association of the Mountain Pacific. Our mission is to save lives by improving lung health and preventing lung disease. The use of such devices — which are not regulated by the FDA — in public places and workplaces may complicate efforts to enforce and comply with smoke -free laws. And because they have not been thoroughly evaluated, the American Lung Association supports including them in smoke -free laws and ordinances at worksites and in public places. We urge you to pass Bill 302 as one more step to better protecting the public health of Hawaii's kama'aina and community. Thank you for the opportunity to provide testimony. Kind regards, Kim Nguyen, MSW Executive Director — Hawaii American Lung Association of the Mountain Pacific M Cancer Action Network - October 13, 2014 Councilmember Brenda Ford, Chair Councilmember Margret Wille, Vice Chair Committee on Public Safety and Mass Transit Hawaii County Council American Cancer Society Cancer Action Network 2370 Nu'uanu Avenue Honolulu, Hawai' i 96817 808.432.9149 www.acscan.org Bill 302 - AN ORDINANCE AMENDING CHAPTER 14 ( GENERAL WELFARE), ARTICLE 4 OF THE HAWAII COUNTY CODE 1983 ( 2005 EDITION, AS AMENDED) RELATING TO PROHIBITION OF SMOKING IN CERTAIN PLACES AND THE USE OF ELECTRONIC SMOKING DEVICES. Cory Chun, Government Relations Director — Hawaii Pacific American Cancer Society Cancer Action Network Thank you for the opportunity to provide testimony in support of Bill 302, which amends Hawaii County's smoke -free ordinance to prohibit the use of electronic smoking devices in places open to the public where smoking is prohibited. The American Cancer Society Cancer Action Network (ACS CAN) is the nation's leading cancer advocacy organization. ACS CAN works with federal, state, and local government bodies to support evidence -based policy and legislative solutions designed to eliminate cancer as a major health problem. ACS CAN supports prohibiting the use of electronic smoking devices where smoking cigarettes is already prohibited. The use of e- cigarettes in public places normalizes the act of smoking and undermines Hawaii's successful efforts to create a smoke -free environment that models healthy behavior, especially for a new generation of young people. This simulation of smoking also makes enforcement of the current smoke -free workplace law difficult because of the similarities between the two. Thank you for the opportunity to submit testimony on this matter. Uplifli►tg the Nation Hid Udlan)a 01a Nit `Oiwi Native Hawaiian Health Care System 10/13/14 To: Committee Chair Honorable Brenda Ford and Committee members, Public Safety Re: Strong Support for Bill 302, Relating to Electronic Smoking Devices Aloha e Ms. Ford and the Public Safety Committee Members, On behalf of Hui Malama Ola Na `Oiwi, the Native Hawaiian Health Care System for Hawaii Island, we thank you for the opportunity to submit testimony in strong support of Bill 302. We strongly support prohibiting the use of ESDs in places open to the public and places of employment. We support including "electronic smoking devices" in the definition of "tobacco product" and "smoke or smoking" in the County of Hawaii, and to prohibit the use BOARD OF DIRECTORS of electronic smoking devices in the places where smoking is prohibited. Including Uahe•l De Si /e'u, Chair David.l. lvrelr. Vice -Chair electronic smoking devices will protect the public, reduce confusion within society, laais llaa, a Itr7re decrease distractions in the workplace, and maintain the social norm. Robet•J it•1. Yunutdtt !l, Treasurer Marlene Halmi. 110). Dean llau'otikeola Pakele We support treating ESDs similarly to other tobacco products and restricted to the Leona k'unmile Seto -dlonk same sale, distribution, and display requirements as cigarettes and other tobacco DIREC'1.OR EMERITUS lVinifred Pele Miami p roduets. EXECUTIVE DIRECTOR Michelle •+Naha lhraishi KILO OFFICE 69 Railroad .-Ivenue. Suite AA Hilo, 111967�711 MON 469 -9220 (808) 961.4794 /ax wvv� +•.httiatalttmaulcautoiwi. t»',>; KAT OFFICE (M8) 929- 97rttl (808) 919- 9744,1ii.v KONA OFFICE t808) 323-3618 (A'081323- 20961x.% PAHOA OFFICE (808) 965 -5.521 t80& 965-3527 fax WAIMEA OFFICE (808) 964 -4210 (8(181941- 4794,har Yonr Notive Nawaitart partner in healthy hvinQ! Electronic smoking devices are currently unregulated and emit unregulated levels of chemicals into the air. Without regulations there is no evidence that the emissions are merely "harmless water vapor." We urge you to pass Bill 302 in order to provide protection for the public while science continues to emerge with more information about the emissions and chemicals released from the vapor. Failing to act may set us back decades. Mahalo nui loa for your efforts to improve the health of our island's people. Michelle M. Hiraishi Executive Director Hui Malama Ola Na `Oiwi a jour KTA SUPER STORES October 13, 2014 50 E. Puainako Street, Hilo Hawaii 96720 Phone (808) 959 -4575 , Fax (808) 959 -8050 To: Committee Chair Brenda Ford and Public Safety Committee members Re: Bill 302, Relating to Electronic Smoking Devices Thank you for the opportunity to submit testimony in support of Bill 302, Relating to Electronic Smoking Devices. We support the application of Hawaii County's laws regarding tobacco smoking to electronic smoking devices. We further support including "electronic smoking devices" in the definition of "tobacco product" and "smoke or smoking," and to prohibit the use of electronic smoking devices in the places where smoking is prohibited. Electronic smoking devices (ESDs) should be treated similarly to other tobacco products and restricted to the same sale, distribution, and display requirements as cigarettes and other tobacco products. KTA treats ESDs in the same manner as cigarettes. Customers and employees are not allowed to use ESDs in our stores and are restricted to smoking ESDs to designated smoking areas. We urge you to pass Bill 302. Sincerely, Barry K. Taniguchi Chairman & CEO KTA Super Stores COALITION FOR A TOBACCO- FREE HAWAt'1 To: The Honorable Brenda Ford, Chair, Committee on Public Safety and Mass Transit And the Honorable Members of the Hawai'i County Council From: Tami MacAller, MPH, MCHES, CTFH West Hawaii Community Coordinator Date: October 13, 2014 Hrg: Public Safety Committee; Tues., October 14, 2014 at 2:00 p.m. in West Hawaii Civic Center Chambers Re: Strong Support for HC Bill 302, Relating to Electronic Smoking Devices Thank you for the opportunity to offer testimony in strong support of HC Bill No. 302, which regulates electronic smoking devices (ESDs). The Coalition for a Tobacco Free Hawaii (Coalition) is a program of the Hawaii Public Health Institute working to reduce tobacco use through education, policy and advocacy. The Coalition supports including ESDs by amending chapter 14 (general welfare), article 4 of the Hawaii county code 1983 (2005 edition, as amended) relating to prohibition of smoking in certain places and the use of electronic smoking devices, which will provide for further consistency and protection in the workplace, and other areas where tobacco use is prohibited in Hawaii County. HC Bill 302 adds and amends important definitions of the law, which are critical to allowing consistency among all of Hawaii County's smoking laws. Confusion of smoking prohibitions results without such definitions in place. Furthermore, emerging research shows dual use where cigarette users switch to ESDs in locations they are not permitted to smoke.I Allowing the use of ESDs in locations where smoking is prohibited is problematic in that ESD use threatens the social norm, creates distractions in the workplace, and undercuts years of progress by tobacco control groups. Currently in Hawaii, ESDs are not regulated at any level; therefore all emissions and chemicals released in exhalation are also unregulated. ESDs do not emit harmless water vapor, but emit an aerosol that contains nicotine, ultra -fine particles, volatile organic compounds, and other toxins.2 The U.S. Food and Drug Administration (FDA) has not found consistent control processes within the manufacturing of ESDs. Restricting ESD use is a growing trend across the US. Currently, at least 110 counties restrict the use of ESDs, including New York City, Los Angeles, Long Beach, and San Diego. 1 Centers for Disease Control and Prevention (CDC). Notes from the field: electronic cigarette use among middle and high school students -- United States, 2011 -2012. MMWR Morb Mortal Wkly Rep. 2013;62:729 -730. Available at http: / /www.cdc.gov /mmwr/ preview /mmwrhtml /mm6235a6.htm ?s cid— mm6235a6 w '- Americans for Nonsmokers' Rights, "Electronic (e -) Cigarettes and Secondhand Aerosol ", available at http://no- smoke.org/pdf/ecigarette-secondhand-aerosol.pd f. 850 Richards Street Suite 200 • Honolulu, HI 96813 • (808) 591 -6508 • www.tobaccofreehawaii.ore *The Coalition for a Tobacco -Free Hawaii is a program of the Hawaii Public Health Institute %W COALITION FOR A TOBACCO -FREE HAWAII Manufacturers and retailers acknowledge that ESDs contain nicotine, are addictive and habit - forming, are intended for committed smokers, and should not be used by women who are pregnant or persons with an elevated risk of any medical condition, including, but not limited to, heart disease, diabetes, high blood pressure or asthma.3 As a public health educator I have had many requests recently from West Hawaii middle schools to educate students on the harms of ESD's. When asking students if they had ever used an ESD, over 75% of the students at one school responded "yes" when asked if they had tried ESD's. They had been told that the flavored a juice was safe to use. Most flavored a juice contains diacetal and proplylene glycol. These chemicals are for food additives, but not made for inhaling. When heated (ESD's heat at over 600° F) these chemicals become airborne respiratory irritants, causing upper respiratory irritation -to people around the user and have been found to cause asthma in children.4 In closing, local concern about ESD use is growing. Since ESD's are smoked, most of the local hotels ban ESD use as a part of their Smoke -Free policy. Local restaurants haven't had many issues with ESD users and will ask customers who are using to go outside. Some establishment allow ESD use until another customer complains. One grocery store has a "No Smoking — Including ESD" sign posted, other stores hope to have signs soon but will kindly ask a customer to use outside. This past weekend as I was volunteering to catch finishers at the Ironman Triathlon, I personally witnessed someone using an ESD around these athletic champions. The user who was also volunteering was asked to stop or leave the area... Just what was he thinking? That after a 140+ mile Ironman event — it would be safe for athletes to inhale ESD aerosol? I urge you to pass Bill 302 in order to provide protection for the public. Failing to act may set us back decades. Thank you for the opportunity to testify on this matter. Tami MacAller MPH, MCHES West Hawaii Community Coalition Coordinator 3 http: / /www.eiuigeusa.com/wamings =- read- me.nhp; www.vapedudes.com/; http: / /www.vaportokei's.com,; http: / /www.virginvgpor.com/; hUD:Hww,,v.voicanoecigs.com/about-us a Offerman FJ, The Hazards of E- Cigarettes. ASHRAE, 38 -44. 2014 850 Richards Street Suite 200 - Honolulu, HI 96813 - (808) 591 -6508 - www.tobaccofreehawaii.org *The Coalition for a Tobacco -Free Hawaii is a program of the Hawaii Public Health Institute 0 L.A. Times Santa Monica bans e- cigarettes in public places Tre'vell Anderson October 15, 2014 Santa Monica became the latest city to strictly regulate where e- cigarettes can be smoked, banning their use in most public places. On Tuesday, the City Council voted unanimously to enact tough restrictions on the devices, essentially treating them like regular cigarettes. Santa Monica joins other cities that passed similar measures earlier this year, including Los Angeles, Long Beach and Beverly Hills. The decision came after months of discussion about the safety of e- cigarettes for former smokers and others. Although supporters of "vaping" argue that they have helped people quit smoking and are a safe alternative to regular cigarettes, critics say that they target young people and could be a gateway to increased smoking among youths. "There is no clear evidence that these devices are safe, despite there being a lot of studies," said Adam Radinsky, head of the city's Consumer Protection Unit. The new ordinance will take effect Nov. 14, when e- cigarettes will be banned in public places and vapor retailers will have to obtain a tobacco license. "There seems to be growing evidence that they have health risks and some serious problems." Radinsky says that the city is also concerned about e- cigarettes' potential popularity among children and said allowing the devices made it harder for the city to effectively enforce its smoke -free laws when, from a distance, e- cigarettes and traditional cigarettes look similar. Santa Monica's new ordinance essentially treats "vaping" as smoking. The sale of e- cigarettes to minors will be prohibited, retailers will have to obtain a tobacco license and vapor bars will also have to prohibit in -store smoking, though that rule will not apply to the city's two current vapor bars, Fix Vapor on Main Street and Vapor Delight on Lincoln Boulevard. Despite the exemption, Vapor Delight's owners said they are still concerned, Bearing the brunt of this new ordinance will be those who have successfully quit smoking by using vapor cigarettes that don't contain tobacco, they say. "Vaping is not smoking," said Omar Abaza, 30, who with his cousins Dean Ascar and Ashraf Spahi owns Vapor Delight. E- cigarettes are seen as an alternative to smoking because they allow users to adjust nicotine intake as they wean themselves from it. The nicotine levels in vapor cigarettes range from o to 24, in increments of 3. A 24 level of nicotine is equivalent to that of a cigar, Abaza said. "Now they're going to be forced to sit along with those cigarette smokers again and be included and get secondhand smoke," Abaza said of those who quit smoking through the use of vapor cigarettes. "It's futile to quit, but yet have to be grouped with the people still smoking." In March, Long Beach passed one of the strictest laws in the state on e- cigarettes, classifying them as tobacco products, banning their sale to those younger than 18 and subjecting vendors to inspections and potential sting operations by the city's Health Department. trevell.anderson @latimes.com http: //www.latimes.com/ local / westside /la- me- santa - monica - cigarettes- 20141o16- story.html iiiiiii iiiiiiiiiiiiii�7Tir TW-A es , Improving All Buildings Boulder Valley School D.3triCt Capital Improvements Bond Benefiting All Students DailyCamera Boulder, CO l Now 63° (http://www.dailycamera.comfboulder- (http' / /www.dailycamera.com) v' /east er ;,ealh -30 I High 67° (httpJlwww.dailycamera.com/boulder- (http iio,w:v.da,l camera.com, boulder- [, weather) I Low.41° (httpiiwww.dailycamera.comlboulder- LOUISVILLE NEWSathO /LOUISV,,I 5 P °�, t� c) HOT TOPICS: Boulder development Mt ://www.d is 1 camera.com /news /boulder /ci 267748391 AdCho¢es f> Louisville pulls the plug on e- cigarettes Electronic smoking devices, vapor pens banned in public places By Doug Pike Colorado Hometown Weekly POSTED: 09/16/2014 09:48:14 PM MDT I UPDATED: 46uu7 A MONTH AGO Louisville e- cigarette and vapor pen users, welcome to the smoking section. The Louisville City Council on Tuesday night passed an ordinance amending the city's municipal code to ban the use of electronic smoking devices in public places, restricting the practice in the same manner as tobacco cigarettes. The city staff recommended the outright ban based on the potential health risks of e- cigarette vapor, the possibility of law enforcement mistaking e- cigarettes for tobacco cigarettes and the undesired exposure of youth to behaviors that might encourage smoking. The council last visited the issue during a July 15 meeting, at which point vapor product users implored council members to seek more information before making a decision. The FDA has yet to officially weigh in on e- cigarettes. Armed with an information packet more than loo pages thick, council members on Tuesday unanimously voted to approve the ban. Louisville was among the first municipalities in the state to pass a smoking ban 14 years ago. Councilman Jeff Lipton, who commended the city's tradition of forward- thinking when it comes to regulating public smoking, said he anticipates little fallout from Tuesday's decision. "I think the prediction (when the city banned tobacco smoking in public) was that the bar business would drop off significantly and that we would kill our downtown," Lipton said. "And I don't see that happening." Louisville joins Lakewood, Golden, Fort Collins, Durango and Edgewater in a growing list of Colorado communities that have banned e- cigarettes. Advertisement The ordinance revised the definition of smoking to closely resemble the state's definition under the Colorado Clean Indoor Air Act and adds the definition of electronic smoking devices. 'herr+" The ordinance prohibits smoking and vaping within 15 feet of open windows, air intakes and outdoor seating. I found it at Barbara & Company! Helping uo— took tlisir6st, and 04far emelm Close Ad X Be the first of your friends to Eke this. Follow LAS ( htti):/ /www.twitter.com /dailycamera) on Twitter Become a fan on Facebook (Jittp [Iwww: facebook com /dailycarnera� %u Subscribe tO LI5 htt / /www. outube.com /thedaL camera • on YouTube y —� " Comments Login or signuo htt :! /intensedebate.com /sionup� now to comment. There are no comments posted yet. Be the first one! Article ID: undefined THE BOTTOM LINE Daily io Seconds with Dana Carvey After you watch our featured video above, you can enjoy cartoon - shorts starring: David Spade, Julianne Moore, Chris Rock and more! LEARN MORE (http://www.dailycamera.com) Home State Bank (http: //m ylocal.da ilyca me ra. com /la fayette- CO/ finance /banks /Home- State - Bank -970- 622 -2394) Baseline Auto (http: / /myloca l.dailyeamera. com /boulder- CO /auto /auto -reps it -and- maintenance /Base line- Auto - 303 -442 -8717 ) Find Boulder Attractions Search for a business Search by keyword or Zip C Add your business here + Login ( http:// mylocal .dailycamera.com / #add_business) AF Vancouver To Banff Train Experience Breathtaking Beauty On A Great Canadian Train Journey Daily Camera ■ ■ Ca E R PASO DEL NORTE HEALTH F 0 U N D A T t b N The Paso del Norte Health Foundation promotes health and prevents disease in the region through leadership in health education, research, and advocacy. Home Priority Areas t Who We Are FAQ's Resources Grant Center !� !P. E- cigarettes and vaping Contact us E- cigarettes and vaping 0 On March 20th, the City of Socorro tweaked its municipal clean indoor air ordinance, by changing the definition of smoking to include "electronic cigarette or e- cigarette or liquid nicotine." By doing so, Socorro now prohibits the use of electronic cigarettes in restaurants, bars, and other indoor work environments. This decision makes Socorro the first municipality in the region to join Los Angeles, Chicago, New York, and other cities to treat electronic cigarettes like conventional cigarettes. While many cities are considering this type of change to their existing ordinances, the emergence of 'vaping' retail stores across the U.S suggests that the e- cigarette phenomenon is not going away. Interestingly, non - smokers often don't know what e- cigarettes are. Electronic cigarettes (also called vape pens) are typically battery - operated devices that contain cartridges with nicotine, flavor, and other chemicals Once ignited. the mechanism converts the contents of the cartridge into wpor, which is then inhaled by the user. "To vape" is the verb associated with electronic cigarettes: it's another way of saying that an individual is inhaling the vapor produced by an electronic cigarette. The Centers for Disease Control and Prevention (CDC) estimate that 1 in 5 adult cigarette smokers has tried an electronic cigarette In many cases, cigarette smokers try e- cigarettes as a tool to quit smoking. While there is anecdotal evidence in both directions. there is no existing scientific evidence that e- cigarettes are an effective smoking cessation tool. What's the concern? Up to now, the research on e- cigarettes is limited. Consequently. consumers currently do not know: the risks of e- cigarette use, the quantity of nicotine or other chemicals inhaled when \raping. or possible benefits associated with these products The U.S. Food and Drug Administration (FDA) has not evaluated e- cigarettes for safety or effectiveness. Nonetheless. there are some caution signs for these products' The FDA found that the various brands of e- cigarettes have differing quality control processes. For example. three different electronic cigarette cartridges, with the same label, contained markedly different amounts of nicotine. E- cigarettes cartridges include fruit and candy flavors. There is some concern that these flavors are being marketed toward youth. The CDC reports that 10% of U.S. high school students have tried e- cigarettes. The FDA analyzed the contents of two leading brands and found that both contained tobacco specific nitrosamines, a class of chemical compounds that have carcinogenic properties Big Tobacco is on the verge of becoming Big Vapor Large tobacco companies.. like the Altria Group and R. J Reynolds, continue to move into the electronic cigarette market. Aitria Group. the maker of Marlboro. is working to expand its MarkTen e- cigarette brand. R J. Reynolds has its own subsidiary R J Reynold's Vapor, which will be launching its Vuse brand later this summer. Vapor shops; including local retailers. and many smokers claim that e- cigarettes are safer than traditional cigarettes. With the emergence of e- cigarettes and the legalization of recreational marijuana in two states, the world of smoking is changing rapidly. To make wise health choices, we need to keep our eyes on research and evidence While the relative safety of e- cigarettes may seem logical. necessary studies are not available For now, the long -term impact on health of e- cigarette usage is not known For more information, contact Jon Law, Chief Operating Officer Paso del Norte Health Foundation at or 915- 544 -7636 Tweet 0 cm S%QV Qv%d mah9v qrQpe vanilla -- Nicotine NOT 1S