Commentary: Indoor Air Pollution from E-cigarettes
 By James Repace, October 13, 2013 (Published in . Reproduced by author’s permisssion for EMASH)

The growing popularity of e-cigarettes among smokers has led to increased availability with a number of new manufacturers entering the market every year. Also, these devices are being used in spaces where smoking has been banned, leading to increased indoor air pollution despite reductions in building air exchange rates. The few extant studies of e-cigarette emissions, although limited in the number of products tested, show that these devices pollute indoor air. Nevertheless, they are being promoted as “emitting only harmless water vapor,” when studies show the emission of polluting VOCs, as well as heavy metals and fine and ultrafine particles.
There is little or no quality control in, or government oversight of the manufacture of E-liquids. If dozens of so-called “vapers” begin to frequent bars, restaurants, discos, offices, and are permitted to fog the air on aircraft, decades of progress in cleaning up indoor air in workplaces and public access buildings is on the threshold of reversal. This is a very dangerous development.
According to the New York Times (2013), a decade after The New York City Council and Mayor Michael R. Bloomberg’s smoking ban in public places, it is returning to the city’s offices, bars, restaurants and workplaces, thanks to the growing popularity of e-cigarettes. Growing in popularity, a major draw is that they allow smokers to indulge in places where their habit had been circumscribed or outlawed. According to a spokeswoman for the Mayor, “e-cigarettes are not covered under any current policies, and can be legally used in bars and restaurants.” Big Tobacco is jumping on the bandwagon: The Wall Street Journal (2013) reported that “According to a report from Bloomberg Businessweek, big tobacco is looking into new territory with Reynolds American unveiling its Vuse e-cigarettes in July and the largest cigarette maker, Altria Group [Philip Morris], following suit with its MarkTen e-cigs in August. Even Playboy is getting in on the act, with the well-known brand lending its iconic bunny symbol to a whole new line of premium electronic cigarettes.”
E-cigarettes are now being used to inhale marijuana in public places, and recently I received an email advertising a large-capacity “E-cigar” (ITeam, 2013; Shenzhen, 2013). E-cigarette use is skyrocketing among US middle and high school students (Washington Post, 2013). A recent editorial in The Lancet noted that: “… e-cigarettes also pose a serious danger of renormalising smoking. Given that most e-cigarettes are designed to mimic cigarettes in as many ways as possible, being around people lighting up— electronically or otherwise—will once again become socially acceptable.
Tireless campaigning has drawn attention to the dangers of second-hand smoke to others; the normalisation of e-cigarettes will confuse those efforts.”
In one of the first peer-reviewed studies of e-cigarette emissions from three different products in a chamber study, Schripp et al. reached the following major conclusions: that the e-cigarette is a new source of VOCs and ultrafine/fine particles in the indoor environment. Schripp accordingly coined a new term: “passive vaping.” They further note that the impact of e-cigarette vapor inhalation into the human lung of non-users should be of primary concern. Schripp et al. tested only 3 brands of e-cigarettes.
However, one website lists 22 different “top brands” (CocktailNerd, 2013).
We do not know which, if any, of these Schripp et al. might have tested.
Despite these limitations, Schripp has debunked the claim that e-cigarettes only emit “harmless water vapor.” Vardavas et al. (2011) noted that different manufacturers use different designs and incorporate a range of ingredients, and there is limited evidence on the actual constituents of each brand. There is no regulation of these pharmaceutical products, and active and passive users are at the mercy of the quality control and quality assurance of each of the individual overseas manufacturers.
Moreover, Vardavas et al. (2011) reported “adverse physiological effects in users of e-cigarettes after 5-minute inhalation, including increases in pulmonary impedance, peripheral airway flow resistance, and oxidative stress among healthy individuals, similar to some of the effects seen with tobacco smoking and worthy of further investigation.” Vardavas et al.’s study suggests that the effects of breathing e-cigarette vapors (passive vaping) may induce more severe breathing difficulties in nonsmokers.
More recently, Williams et al. (2013) testing a single brand of E-cigs, reported that the aerosol contained particles >1 nm comprised of tin, silver, iron, nickel, aluminum, and silicate, was well as nanoparticles (<100 nm) of tin, chromium and nickel. The concentrations of nine of eleven elements in E-cig aerosol were higher than or equal to the corresponding concentrations in conventional cigarette smoke. Many of the elements identified in the aerosol are known to cause respiratory distress and disease. EPA's IRIS data base should be used for every chemical in the E-liquid.
I pointed out in comments to FDA, that much work needs to be done.
The World Health Organization stated that some manufacturers have claimed that E-cigarettes can be used legally in environments where smoking is prohibited. WHO strongly recommends that E-cigarettes not be exempted from ‘clean air’ laws, which restrict the places in which cigarette smoking is allowed, until adequate evidence is provided to assure regulatory authorities that use of the product will not expose nonusers to toxic emissions.
In comments to the US Department of Transportation [Docket No.DOT-OST-2011-0044, RIN No. 2105-AE06, Smoking of Electronic Cigarettes on Aircraft, I wrote in part the following: It is obvious that E-cigarettes emit an aerosol when puffed. Aerosol in the outdoor air (PM2.5) is a regulated air pollutant with no known threshold for acute and chronic effects on the cardiovascular system. It may also contain ultrafine particles, and does contain VOCs of various sorts, including various unregulated chemicals of unknown composition, plus glycols and nicotine, which is a known toxin. It is also known that air pollution affects people differently depending upon their health status and sensitivity. The hypothesis being advanced by proponents is that there are no acute or chronic health effects or air pollution impacts if these devices are used in currently smoke-free areas.
This hypothesis is unsubstantiated by research, and E-cigarettes remain unregulated products of mostly unknown composition.
An appropriate research program would start by collecting multiple samples of each of the two dozen or more brands currently being marketed and analyzing the E-liquids in them. Next, multiple tests would be run on the devices when they are smoked under controlled circumstances in an experimental chamber to determine emission factors for each of the components of toxicological interest, including carcinogenic potency. In this manner, the standard mass-balance model can be used to predict their concentrations in occupied spaces. Next, panels of healthy nonsmokers and sensitive nonsmokers would be employed to test the odor, irritation, and cardiorespiratory impacts of exposure to E-cigarette vapor, using standard butanol wheel, eye-blink, pulmonary function, and heart rate variability tests. This would allow public policy to be based on science, rather than speculation. Of course, such studies would involve multi-million dollar research grants and multidisciplinary researchers involved. Then the peer-reviewed and journal-published data would be reviewed by impartial expert panels of national and international agencies.
The introduction of new contaminants into the air of public places will expose the general public and workers to unknown risks. In the wake of widespread smoking bans as well as energy conservation measures, ventilation rates in buildings have declined precipitously. For example, under the old ASHRAE Standard 62-1999, Ventilation for Acceptable Indoor Air Quality, the prescribed ventilation rate for a restaurant dining room was 20 cubic feet per minute per occupant, with a default occupancy of 70 persons per thousand square feet; by 2004, ASHRAE Standard 62.1 2004, the new rate was cut in half, to 10 cfm/occupant, where it currently remains. The introduction of new uncontrolled contaminants into the air of buildings should be viewed with alarm by clean indoor air advocates.
In summary, it appears that decades of progress in cleaning up indoor air is on the threshold of reversal. Whatever the real or imagined benefits of “vaping” to the smoker, they should not be permitted in places where smoking is banned. To do so, in my view, is a very dangerous development.

Commentary: E-cigarettes renormalize smoking in public
By Prof. T. Abelin, Bern, Switzerland. January 9, 2014.

The Commentary of James Repace on e-cigarettes and their potential harmfulness is well taken and supports the view that e-cigarettes should not be admitted at all, or only with severe restrictions and after further research has been completed. But the general discussion of admitting e-cigarettes is too narrow, when only the health effects of their emissions and their potential to enable cigarette smokers to bridge times of abstention from cigarettes are considered. 
  A dimension of equal importance is the potential role of e-cigarettes in interfering with current strategies to reach the long-term objective of ending the global tobacco epidemic. In these strategies "denormalizing smoking" is of central importance in connection with several measures of the WHO Framework Convention on Tobacco Control, including restrictions on packaging and labeling of tobacco products (Article 11), a comprehensive ban on advertising, promotion and sponsorship (Article 13) and prohibiting sales of tobacco products to minors (Article 16). Research has shown that these measures are effective in "denormalizing smoking" and reducing demand for tobacco products, in particular among youth. Permission of marketing electronic devices looking like cigarettes would make it possible to "renormalize smoking" without actually breaking tobacco control laws, and as tobacco companies are entering into the e-cigarette market, they open their way to use these products as a means to circumvent tobacco control legislation.
 This is not a theoretical consideration. Until recently, although Swiss laws banned all TV advertising for alcoholic beverages, a leading brewery regularly broadcasted TV spots typical for promoting beer consumption and its particular brand, except that during the last moments a note appeared saying "Non-alcoholic beer".  These spots disappeared when the country adopted EU regulations permitting TV advertising for beer. Similarly, many of the denormalizing measures of the FCTC could be circumvented by the tobacco industry, if e-cigarettes were allowed to be sold, because the view of cigarette smokers and e-cigarette "vapers" could be presented in almost identical ways, and cigarette brands and logos could be promoted under the pretext of promoting e-cigarettes.
 What can be done to prevent this from happening? Legislators and regulators should be aware of this risk and act so as not to threaten the control of the tobacco epidemic. This means to keep e-cigarettes from the market altogether or at least include them explicitly in the tobacco control regulations. And in order to prevent the risk of interference with tobacco control policies,where permitted, all e-inhaling devices (including non-nicotine devices) should be obliged to look like medical inhaling devices rather than cigarettes, cigars or pipes. I suggest that those engaged for a smoke-free society should advocate for these demands, regardless of the harmfulness of inhaling the vapor of e-devices.
  Theodor Abelin, MD, MPH
em. Professor of Social and Preventive Medicine, University of Bern
Seelandstrasse 23
CH-3095 Spiegel b. Bern