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Electronic nicotine delivery systems in the workplace: Harm reduction or hidden liability?

Electronic nicotine delivery systems (ENDS), commonly known as electronic cigarettes (e-cigarettes) or vapes, represent a rapidly growing tobacco market segment. An understanding of the origins, mythology, and hazards of these devices is needed as employers define policies on ENDS.

One moment in history transformed tobacco use from something subject to ceremonial and limited recreational use into a commodity. The introduction of the Durant cigarette machine at the Paris Exposition of 1878 signaled the availability of a convenient and affordable tobacco product in the form of machine-rolled cigarettes [1].

Subsequent improvements, most notably the introduction of the filter cigarette following World War II, contributed to exponential growth in global tobacco use. By 1973, world cigarette consumption was 4.6 billion per year—roughly equivalent to one cigarette for every man, woman, and child on the planet [1]. Tobacco use continues to be the leading cause of preventable disease in the US, although use has decreased in recent decades due to tobacco control strategies, including public health education [2].

Although not a factor in the restriction of tobacco use in the workplace, nicotine is a psychoactive drug that meets the criteria for drug dependence established by the US Surgeon General [3]. Tobacco is restricted in most workplace environments owing to physical hazards (presence of an open flame), the potential for product contamination, and the potential to expose others to harmful substances via secondhand or thirdhand smoke.

The critical question is whether workplace restrictions should change with the expanding use of electronic nicotine delivery devices.

ENDS are not a 21st-century concept but were first developed in 1962 by British American Tobacco under project Ariel [4]. In developing an electronic cigarette, researchers recognized the use of pure nicotine would render Ariel a drug delivery device; the development strategy was, therefore, to create an extract that “just by good luck” contained a lot of nicotine. The project was not launched commercially, and the patents expired in 1984.

blog 3The modern Electronic Nicotine Delivery System (ENDS), also known as an e-cigarette or vape, is constructed in a manner very similar to the original electronic cigarette. An ENDS consists of a battery-powered atomizer and heated metal coil connected to a liquid reservoir by a wick typically made of cotton or silica. Upon activating the device, the metal coil heats and the liquid in the reservoir is wicked into the atomizer forming an aerosol that is inhaled [5]. The liquid (called “vape juice,” “e-liquid”) is composed of varying ratios of humectants (vegetable glycerin, propylene glycol), flavoring agents, and nicotine (not all liquids contain nicotine).

The nicotine used in ENDS liquids is almost exclusively extracted from tobacco plants, not synthesized. As such, ENDS liquids are correctly classified as a tobacco product.

A decrease in the consumption of combustion tobacco products has accompanied the rise in popularity of electronic nicotine delivery systems (ENDS) [6]. ENDS provide a covert means to use tobacco where smoking is prohibited, and are additionally favored due to the low odor and lack of teeth staining associated with tobacco smoking. With absorption kinetics more closely mimicking that of smoking, ENDS manage cravings more effectively than nicotine inhalers or nicotine gum [7].

A billion-dollar market [8, 9], potentially surpassing combustible cigarette consumption by 2023 [5], ENDS are somewhat grudgingly acknowledged as a valid harm reduction strategy [7] because the levels of toxicants in ENDS aerosol are significantly lower than in traditional tobacco cigarette smoke [10]. Some estimates place the risk of mortality from vaporized nicotine products at only 5% of that from smoking tobacco; a risk comparable to the mortality risk from smokeless tobacco [6]. That said, this emphasis on the potential for harm reduction by tobacco and electronic cigarette companies may have undone decades of public health education on tobacco [11], but that is a topic for another day.

In the workplace, a relevant question is whether the use of ENDS poses a risk to persons other than the smoker.

Among ENDS users there is a mistaken impression of the absence of health risks [8], and misleading marketing reinforces these beliefs by portraying ENDS products as producing nontoxic emissions that can be safely used indoors [12]. While it is true that modeling data indicate that electronic cigarette aerosol has a half-life of only 11 seconds (compared to 19-20 minutes for cigarette smoke) [13], potent carcinogens, known as tobacco-specific nitrosamines, are present in ENDS aerosol [14]. The exhaled aerosol contains only about 3% of the inhaled nicotine and consists predominantly of humectants such as glycerol and propylene glycol [13].

Further, empirical data indicate that non-users are exposed to nicotine of sufficient concentrations to result in elevated levels of cotinine, the primary urinary metabolite of nicotine [15]. In addition to the rapid absorption kinetics following inhalation exposure, nicotine is readily absorbed dermally, and studies have demonstrated systemic exposure to nicotine from tobacco smoke-exposed garments [16]. Additionally, ENDS emissions are deposited in the indoor environment and these deposits can be re-emitted in a process known as thirdhand exposure [17].

Proponents of the ENDS technology are quick to draw a comparison between cigarettes and the significantly lower emissions of ENDS, yet the data indicate non-zero risk of ENDS to both those who smoke with the device and to the non-users sharing the indoor environment with the smoker. Respiratory symptoms, eye irritation, headache, and nausea are among the range of effects reported by non-users exposed to ENDS aerosol [18]. Although typically self-limiting, some cases of secondhand exposure require medical attention.

Although initially predicated on a preference for clean indoor air, modern smoke-free policies are based on decades of data demonstrating the harm of secondhand smoke [19]. Any suggestion that ENDS emissions are “benign” is demonstrably false: ENDS secondhand aerosols vary in composition by the manner of use and the particular device, but the available data indicate a significant dispersion of humectants, nicotine and PM2.5 [20], the latter a significant risk factor for cardiovascular mortality.

In the case of workplace tobacco policy, ENDS are a tobacco product; their use in the indoor environment poses risks to both users and non-users.

 

References:

  1. Voges, E., Tobacco Encyclopedia. 1984, Federal Republic of Germany: Tobacco Journal International.
  2. Jamal, A., et al., Tobacco Use Among Middle and High School Students – United States, 2011-2016. MMWR Morb Mortal Wkly Rep, 2017. 66(23): p. 597-603.
  3. Nicotine Safety & Toxicity, ed. N.L. Benowitz. 1998, New York: Oxford University Press.
  4. Risi, S., On the Origins of the Electronic Cigarette: British American Tobacco’s Project Ariel (1962-1967). Am J Public Health, 2017. 107(7): p. 1060-1067.
  5. Chun, L.F., et al., Pulmonary toxicity of e-cigarettes. Am J Physiol Lung Cell Mol Physiol, 2017. 313(2): p. L193-L206.
  6. Levy, D.T., et al., A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products. Addiction, 2017. 112(1): p. 8-17.
  7. Cahn, Z. and M. Siegel, Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? J Public Health Policy, 2011. 32(1): p. 16-31.
  8. Nayak, P., C.B. Kemp, and P. Redmon, A Qualitative Study of Vape Shop Operators’ Perceptions of Risks and Benefits of E-Cigarette Use and Attitude Toward Their Potential Regulation by the US Food and Drug Administration, Florida, Georgia, South Carolina, or North Carolina, 2015. Prev Chronic Dis, 2016. 13: p. E68.
  9. Nichter, M., Lighting Up: The Rise of Social Smoking on College Campuses. 2015: NY University Press.
  10. Canistro, D., et al., E-cigarettes induce toxicological effects that can raise the cancer risk. Sci Rep, 2017. 7(1): p. 2028.
  11. England, L.J., et al., Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate. Am J Prev Med, 2015. 49(2): p. 286-93.
  12. Logue, J.M., et al., Emissions from Electronic Cigarettes: Assessing Vapers’ Intake of Toxic Compounds, Secondhand Exposures, and the Associated Health Impacts. Environ Sci Technol, 2017. 51(16): p. 9271-9279.
  13. Rostami, A.A., et al., A Well-Mixed Computational Model for Estimating Room Air Levels of Selected Constituents from E-Vapor Product Use. Int J Environ Res Public Health, 2016. 13(8).
  14. Westenberger, B., Evaluation of e-cigarettes (FDA Internal Memo dated May 4, 2009), CDER/OPS/OTR, Editor. 2009.
  15. Hess, I.M., K. Lachireddy, and A. Capon, A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Res Pract, 2016. 26(2).
  16. Beko, G., et al., Measurements of dermal uptake of nicotine directly from air and clothing. Indoor Air, 2017. 27(2): p. 427-433.
  17. Davis, E.S., et al., E-Liquid Autofluorescence can be used as a Marker of Vaping Deposition and Third-Hand Vape Exposure. Sci Rep, 2017. 7(1): p. 7459.
  18. Durmowicz, E.L., S.F. Rudy, and I.L. Chen, Electronic cigarettes: analysis of FDA adverse experience reports in non-users. Tob Control, 2016. 25(2): p. 242.
  19. Chapman, S., M. Daube, and W. Maziak, Should e-cigarette use be permitted in smoke-free public places? No. Tob Control, 2017. 26(e1): p. e3-e4.
  20. Whitsel, L.P., et al., Guidance to employers on integrating e-cigarettes/electronic nicotine delivery systems into tobacco worksite policy. J Occup Environ Med, 2015. 57(3): p. 334-43.

Fumifugium is the blog of Renee Hartsook Ph.D. DABT, consulting toxicologist and owner of Takmos LLC. 

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All the trash unfit to eat: Oceanic plastic debris as a human health concern

This week I had the opportunity to meet Captain Charlie Moore, the sailor and oceanographer, credited with discovering in 1997 the North Pacific Gyre, the accumulation of plastic debris floating between California and Hawaii. Some 20 years later Moore presented findings of a longitudinal study at the Southern California meeting of the Society of Toxicology and Environmental Chemistry (SETAC).

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Sacred Heart Chapel at sunrise. Photo by R. Hartsook

This regional SETAC meeting (April 12-13, 2018) was hosted by Loyola Marymount University (LMU). The presence of a scientific conference at a Jesuit university reminded me of something Carl Sagan once wrote:

The notion that science and spirituality are somehow mutually exclusive does a disservice to both. 

A presentation on sustainability at LMU by Vice President of Auxiliary Management Raymond Dennis opened with reference to Laudato Si, Pope Francis’ encyclical on the environment and quickly moved to the science (and dollars and cents) of sustainability at LMU. For example, the food service at LMU diverts pre- and post-consumer organic waste to biofeed and in doing so reduced their average 100 tons of solid waste per semester to 30 tons. The peaceful co-existence of science with faith was reassuring. Dennis spoke with reverence about the need to care for the environment as an extension of faith.

It was with the same tone of reverence that Charlie Moore spoke of the oceans. A sailor by training, Moore has conducted detailed research on trends in the debris in the North Pacific Gyre. He was quick to acknowledge that the lack of availability of robust methods to reliably sample the gyre limit the value of his 15-year time series assessing trends in plastic marine debris. For example, the gyre has a moving center of accumulation, so sampling from the same geographical location (as was done in his time series) does not tell us about the behavior of the center of accumulation. He was one of several presenters who highlighted methodological limitations hampering research more than 20 years after the discovery of the gyre.

29011562 - modern urban wastewater treatment plant.Perhaps one would argue that sampling an area so large as the Pacific is unavoidably complicated. Well, it turns out that microplastic sampling methods for something as geographically constrained and easily accessible as wastewater treatment are still lacking. USEPA Region 9 scientist Anna-Marie Cook highlighted the need for basic science on the topic as there are no reliable data on how much plastic escapes wastewater treatment (you may see estimates floating around—no pun intended—but Cook asserts that these are unsupported). She is working on methods to reliably measure microplastics in wastewater influent and effluent.

Some will find the images of seabirds and marine life filled with trash moving, but not moving enough to curtail the purchase of products in plastic containers. Changes in consumer behavior are motivated by either risks or incentives about which consumers care.

20857864_xl.jpgWhile I find compelling the argument that fish from fertile coastal waters represent a significant portion of dietary protein and economic security for the developing world and that microplastics imperil these fish populations, for purchasers of certified sustainable wild-caught salmon, these concerns may seem far removed. This is not so very far removed since plastic pollution is ubiquitous, such that it is impossible to source fish guaranteed free of plastic pollution.

To the consumer, the health impacts of these microplastics may not be apparent since most lay people think of plastic as an inert substance. On the contrary, the most chilling part of the SoCal SETAC meeting were data presented by multiple credible scientists, including scientists from USEPA Region 9, demonstrating unequivocally that plastic particles behave like passive samplers and basically soak up persistent pollutants including PCBs and flame retardants.

In fact, Anna-Marie Cook stated that the contaminant concentration on the surface of a microplastic particle is often one thousand to one million times higher than the concentration of those contaminants in the water. These persistent chemicals, with proven human health impacts, can enter the food web and potentially bioaccumulate and biomagnify. While we must be cautious about overstating the public health impact of this vector of exposure, it is a non-zero exposure and warrants further consideration.

This got me to thinking, what are the solutions to keeping plastic out of the ocean?

  • Don’t buy it (easier said than done)
    • At about 10%, rates of plastic recycling have been stagnant over the past 4 decades (this per Anna-Marie Cook); you may sort it, but that doesn’t mean the plastic gets re-used. Much of what is sorted for recycling ends up as landfill.
  • Advocate for solutions that keep plastic waste out of waterways
    • Waste-to-energy, embraced as a pragmatic solution in Sweden, continues to be a contentious issue in the US (the arguments against to waste-to-energy are not entirely convincing, and a topic for another day).

The issue of marine plastic debris is not an abstract environmental issue but is better likened to undiagnosed cancer—ignoring it will not improve the prognosis.

Until next time.  -Renee

 

Fumifugium is the blog of Renee Hartsook Ph.D. DABT, consulting toxicologist and owner of Takmos LLC. 

Fumifugium – what’s in a name?

Toxicologists are an odd bunch with a tendency to embrace dark and sometimes geeky humor. Take the name of this blog. Fumifugium. What is it?

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Woodblock print from Fumifugium (John Evelyn, 1661) depicting London. Image from R. Hartsook personal collection.

Written in 1661 by noted British diarist John Evelyn and submitted to King Charles II, Fumifugium is among the oldest known public health documents about air pollution. In it, Evelyn describes damage inflicted by air pollution on the art, architecture, and horticulture of London. He depicts scenes at Whitehall in which men “could hardly discern one another” and correctly attributes the sooty vapor engulfing London to the burning of coal. Making reference to three Italian volcanoes, Evelyn asserts that “the City of London resembles the face…of Mount Aetna, the Court of Vulcan, Stromboli, or the Suburbs of Hell.” Not well-received by the College of Physicians (Evelyn was, after all, a country gentleman and not trained in medicine which at the time involved the prodigious use of leeches), Evelyn’s opinions about the impact of air pollution on public health were nonetheless insightful.

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Woodblock print from Fumifugium (John Evelyn, 1661) depicting smoke pollution.  Image from R. Hartsook personal collection.

Identifying coal as the primary source of pollution choking London, Evelyn proposed several remedies including the relocation of coal-intensive industries to the outskirts of the city and the planting of swaths of trees and shrubs (what we might describe as greenbelts). A noted arborist, Evelyn also proposed burning wood instead of coal.

While a graduate student, I acquired a 1933 reprint of Fumifugium from a book dealer in Sacramento, California. Originally intended as a gift for my major professor upon completion of my dissertation, the slight volume with a bland cover seemed an insufficient expression of gratitude. As such, Fumifugium joined my modest collection of antique books. Last week, as I scanned the bookshelf for inspiration to name this blog, the unsightly putty cover caught my eye. After reading the entirety of the treatise for the first time in more than 18 years (which is no small feat given the 17th-century spelling), I embraced the title as the name for this blog. Fumifugium was, after all, a form of modern-day activism in the interest of public health. Given this current moment in history, the name seems apt.

The shifting winds of environmental protection.

Some 48 years ago, the US Environmental Protection Agency (US EPA) was formed by a Republican president—Richard Nixon—in response to environmental disasters impacting public health. In particular, the Cuyahoga River in Cleveland was the proverbial spark for what is now described as an environmental revolution.

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Cuyahoga River in Cleveland, Ohio circa 2018. Stock image (123rf.com).

In June 1969, oil-soaked debris floating on the surface of the Cuyahoga River caught on fire. While a conflagration on this badly polluted waterway was a regular occurrence and hardly registered in local news coverage, a Time magazine article provided sufficient national exposure to prompt the Clean Water Act and the formation of an environmental protection agency that eventually became the US EPA.

That agency is now at a crossroad.

Irrespective of politics, I will offer this regarding environmental protection: being an environmentalist is not an act of idealism, but one of self-preservation. “Mother Earth” is an old inanimate object that will persist long after the last of our kind takes a final breath. To suggest that a planetary object requires protection from humanity lacks both humility and an understanding of basic science. It is humankind, a species far more fragile than many species now extinct, that benefits from environmental stewardship. Choices that impact the breathability of the air, the drinkability of the water, and the health of the ecosystem on which we rely for food, impair our survival.  This is not an abstract concept–we see it every day in communities small and large across the United States. As examples:

So Fumifugium is the name of the blog. What topics will the blog cover?

This blog is an extension of my response to questions on Quora. Recognizing the value in the sharing of scientific ideas and explaining toxicological concepts, I started posting answers on Quora late last year. Quickly a theme emerged; questions related to health risks from environmental factors (e.g., diet, pollution, mobile phone use) were those most frequently asked. From those brief posts grew a desire to share more substantive discourse about a range public health and toxicology topics.

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Illustration of ENDS. Tess Marhofer for Takmos LLC. Copyright 2018.

Currently, I’m working on a series of posts about electronic nicotine delivery systems (ENDS), more commonly known as electronic cigarettes or “vapes.” A largely unregulated industry until recently, ENDS have the distinction of renormalizing nicotine addiction and unraveling decades of tobacco prevention education. In particular, ENDS are popular among young never-smokers who find appeal in the candy-like flavors, the low price, and ease of use. An incorrect perception of ENDS—that they emit only harmless water vapor and can be used safely indoors—is easily disproven by empirical data demonstrating second and thirdhand exposure to nicotine and ENDS solution components. Sadly, an accounting of the public health cost of ENDS will not come for some time, long after the damage is done.

My first post-college job at the American Lung Association and an understanding of how environmental pollution impacts public health have informed my professional and personal interests for decades. My Fumifugium blog aspires to be a modern-day version of Evelyn’s treatise and intended to prompt discourse on topics relevant to public health.

I hope you will follow this blog to receive notifications of new articles. I will not share, sell, or use your information to pester you in any way (what Big Brother does with it, who knows).

Until next time!  -Renee

Fumifugium is the blog of Renee Hartsook Ph.D. DABT, consulting toxicologist and owner of Takmos LLC.