Electronic Cigarettes: Journal of Addiction Medicine
1 RunningHead:E CIGARETTE ORDINANCEISNECESSARY. “Clean Indoor Air? Why Electronic Cigarette Ordinance is Necessary to Promote Public Health.” Jason McCoy North Dakota State University Adviser: Mary Larson
2. 2 E CIGARETTE ORDINANCEISNECESSARY. Abstract Electronic cigarettes (e cigs) pose a unique threat to public health. Currently, more than 263,000 youth in the United States use electronic cigarettes. This is a three-fold increase in just two years. 43% of youth utilizing electronic cigarettes indicate intent to smoke traditional cigarettes. Created to look like cigarettes, they are marketed as cessation devices while not being approved through the FDA. Utilizing a vast variety of flavorings, many of which are youth-centric such as gummy bears and cotton candy, e cigs threaten to renormalize smoking in a population who are finally smoking less than their parents. Currently there are zero federal laws regulating the manufacture, use, marketing, or safety of electronic cigarettes and the refillable liquids utilized. This allows for marketing to youth by tobacco companies, who currently own 49% of the electronic cigarette market. These companies have a proven track record in selling tobacco products. Personal vaporizer units and electronic cigarettes along with the refillable liquids ship are shipped without safety standards. These devices are causing explosions resulting in fires and loss of property as well as personal harm. Science is racing to determine the health effects of utilizing electronic cigarettes. Tobacco funded research is clouding the matter with biased data while public health research is providing health concerns. Expanding state & local ordinances that include electronic cigarettes will provide clarity for government officials and law enforcement needing to deal with these devices. Until the FDA creates official regulations for electronic cigarettes and their refills, it falls on both state and local governments to create laws and ordinance that regulate the use of e cigs. They must be banned from public areas in which traditional cigarettes have already been banned. The only way to ensure
3. 3 E CIGARETTE ORDINANCEISNECESSARY. safe, clean air for everyone is to create policy that will change all of our environment for the healthier
4. 4 E CIGARETTE ORDINANCEISNECESSARY. “Clean Indoor Air? Why Electronic Cigarette Ordinance is Necessary to Promote Public Health.” Electronic cigarettes pose a unique threat to public health. Created to look like cigarettes, they are marketed as cessation devices while not being approved through the FDA. Utilizing a vast variety of flavorings, many of which are youth-centric such as gummy bears and cotton candy, e cigs threaten to renormalize smoking in a population who are finally smoking less than their parents. A lack of federal guidance places the onus for regulation on states and local governments who are being lobbied by traditional tobacco companies who own 49% of the current e cig market as well as smaller “vape” companies who make up for their size with technological savvy and wide market appeal to college and school age constituents. Research is being funded by tobacco and vape organizations muddying the waters for legislators to make a health- conscious decision for their state. Lack of regulation on the federal level also allows marketing tactics to reemerge that were banned in 1999. Electronic cigarettes and their e juice refills may currently advertise on television and billboards, as well as in magazines and point of sale locations. Advertising agencies are bringing back versions of old tobacco advertisements that had great success in the past. Until the FDA creates official regulations for electronic cigarettes and their refills, it falls on both state and local governments to create laws and ordinance that regulate the use of e-
5. 5 E CIGARETTE ORDINANCEISNECESSARY. cigs. They must be banned from public areas in which traditional cigarettes have already been banned. The only way to ensure safe, clean air for everyone is to create policy that will change all of our environment for the healthier. (Fairchild, Bayer, & Colgrove, 2014) Tobacco: Still a Threat in America? Nicotine is still the most deadly preventable threat in the United States. Claiming 480,000 lives in the United States alone last year, cigarette smoking is the leading preventable cause of death. Add another 48,000 deaths from second hand smoke and we have a public health emergency. Beyond mortality, nicotine leads to addiction, along with countless wasted years of productivity & health. (CDC, 2015) According to the CDC “Life expectancy for smokers is at least 10 years shorter than for non-smokers.” (Fairchild, Bayer, & Colgrov, 2014) What about those who do not experience mortality from smoking related causes? Smoking damages nearly every organ in the body. It also causes disease and reduces the quality of health in smokers as well. (U.S. Department of Health and Human Services, 2014) Despite the fact that smoking increases the risk of a great many diseases, nearly 18 of every 100 U.S. adults aged 18 years or older (17.8%) currently smoke cigarettes. This means in the United States there are currently an estimated 42.1 million adults who currently smoke traditional cigarettes. (CDC, 2015) Smoking prevalence is falling in America. However in 2013, an estimated 17.8% (42.1 million) U.S. adults were current cigarette smokers. Of these, 76.9% (32.4 million) smoked every day, and 23.1% (9.7 million) smoked some days. (U.S. Department of Health and Human Services, 2015) These numbers become even more alarming when broken down by ethnicity and socio-economic status.
6. 6 E CIGARETTE ORDINANCEISNECESSARY. American Indian/Alaska Natives (AI/ANs) have the highest prevalence of current smokers than most other racial/ethnic groups in the United States. There are many factors that affect smoking prevalence including sacred tobacco’s ceremonial, religious, and medicinal roles in Native culture, which may affect attitudes, beliefs, and behaviors toward commercial tobacco use. Also, tobacco sold on tribal lands is typically not subject to state and national taxes, which reduces costs. (Caponnetto, et al, 2012) Race/Ethnicity Prevalence American Indian/Alaska Natives (non-Hispanic) 26.1% Asians (non-Hispanic) 9.6% Blacks (non-Hispanic) 18.3% Hispanics 12.1% Multiple Races (non-Hispanic) 26.8% Whites (non-Hispanic) 19.4% Figure 1- CDC 2013 Smoking Prevalence by Ethnicity Smoking rates are higher in men than women, highest amongst ages 25-44,and rates reduce with higher education. (CDC, 2015) However it is also found that when a population is below the poverty level, the smoking rates increase to 29.2%. The population at or barely above poverty level are found to still have smoking rates at 16.2%. Clearly ethnicity, education, and income highly influence the prevalence of smoking in our population. Tobacco, and its addictive component, nicotine, are still a threat in the United States. The continued education from public health which began back in 1972 with the Surgeon General’s first warning that smoking was related to lung cancer has created a gradually changing healthier environment. However, we have a new fox in the henhouse. A new product threatens to
7. 7 E CIGARETTE ORDINANCEISNECESSARY. renormalize smoking in our most vulnerable of populations, our youth. (Fairchild, Bayer, & Colgrove, 2014) Electronic Cigarettes An electronic cigarette (e cigarette) or personal vaporizer is a battery-powered vaporizer that mimics the motions and appearance of smoking a cigarette. (U.S. Department of Health and Human Services, 2015) E cigarettes come in many variations on shape and size. This often makes it difficult to even recognize the device. (Caponnetto, et al, 2012) The original e cigarettes were produced to resemble traditional cigarettes, complete with an LED chip that “glows” like tobacco embers on traditional cigarettes. Most of the least expensive models of e cigarettes today (average cost $10) are still produced to mimic traditional smoking. (Grana, Benowitz, & Glantz, 2014) These less expensive versions are also disposable, usually pre-loaded with two hundred “puffs” of vapor. This is well calculated to mimic smoking as well; a pack of cigarettes averages out to 200 puffs. The more expensive reusable vaporizer units can range in price from $20 up into the hundreds of dollars. (Pepper & Brewer, 2013) These units share in common the ability to purchase refillable liquids. The more expensive models allow the user to regulate the amount of vapor that is produced by the unit. The user, known as a “vaper,” then inhales an aerosol, commonly called vapor, rather than cigarette smoke. (Ebbert, Agunwamba, Rutten, 2015) E cigarettes are comprised of several elements, and these vary by manufacturer. All e- cigarettes contain a heating element that reduces a liquid solution known as e juice into an
8. 8 E CIGARETTE ORDINANCEISNECESSARY. aerosol. (Cheng, 2014) No two e juice brands or flavors have identical ingredients. All of them do contain a base liquid comprised of either propylene glycol or glycerin. Common ingredients are then nicotine, which comes in various strengths, and a plethora of different flavors. (U.S. Department of Health and Human Services, 2015) Figure 2: Diagram of an Electronic Cigarette The first e cigarette was created by Herbert A. Gilbert. In 1963, Gilbert patented "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device produced flavored steam without nicotine. He was granted a patent in 1965. While Gilbert’s e cigarette was ahead of time, it received little attention and was never commercialized. Smoking was still fashionable, and as such no one wanted to pay more for an electronic version of a cigarette. (Weaver, Breland, Spindle, & Eissenberg, 2014) Hon Lik, a Chinese pharmacist and inventor, is given the credit for commercializing the e cigarette. Hon Lik was a research pharmacist for a company producing ginseng products. He had quit smoking after his father, also a heavy smoker, died of lung cancer.
9. 9 E CIGARETTE ORDINANCEISNECESSARY. In 2003, Lik thought of using a high frequency, piezoelectric ultrasound-emitting element to vaporize a pressurized jet of liquid containing nicotine. His design created a smoke-like vapor. The main trouble he ran into was scaling down the device to a small enough size. It is significant to note that Lik intended his e cigarette to be an alternative to smoking. (P.H. ,2014) The modern e cigarette design was patented in 2003. Lik was given the credit for developing the first commercially successful e cigarette. The e cigarette was then introduced to the Chinese domestic market in 2004. Many versions of the e cigarette made their way to the U.S., where they were first sold via the Internet. From there it has grown into a $1.5 billion industry by 2014. This industry is estimated to grow 25% by 2018. Public Health Issues Toxic Chemicals The benefits and risks of electronic cigarettes are hotly contested between public health organizations and what has become known as the “vaping” community. There are a wide variety of both vaporizers and e liquids making research a slow process. Tobacco funded research correctly points out that there is no combustion when using an e cigarette, but they fail to prove the contents of the e liquid, or e juice, are safe for consumption or inhalation. (Goniewicz, 2014) Distributors of e cigarettes promote the product as completely free of harmful substances. The basis for this claim is that they do not deliver toxic doses of nicotine and the nicotine solution lacks harmful ingredients. E cigarettes are relatively new to the
10. 10 E CIGARETTE ORDINANCEISNECESSARY. market and, as such, require further testing to assess their toxic properties. Currently, the scientific evidence on the lack or presence of toxic chemicals in the vapor generated from e cigarettes, and inhaled by their users is very limited. (World Health Organization, 2008) Scientists are researching how much heavy metal, formaldehyde, and other toxic substances are produced in the vapor from e cigarettes. The vaping community assures us that lower levels of toxins indicate a triumph of e cigarettes over traditional cigarettes. Meanwhile, public health advocates are wondering why we need any level of toxins added to the air we all breath. E cigarette vapor contains toxic compounds. Research shows that the levels of toxic compounds are 9 to 450-fold lower than those produced by a traditional cigarette. These causes some researcher to point out that the levels of some of the toxins in e cigarette vapor are comparable to the trace amounts present in pharmaceutical nicotine replacement therapy. (Goniewicz, 2014) A conflicting study found that while the toxins inhaled from e cigarette vapor do preclude those inherent in combustible materials the e juice provides an entirely different matter. Thirty- six liquids were exposed to cytoplasm for toxicity, and it was found that fifteen samples were moderately cytotoxic and twelve samples were highly cytotoxic. (Farsalinos, & Polosa, 2014) Nicotine Exposure Nicotine exposure is one of the largest issues with e cigarettes and e juice. Due to the lack of FDA regulation, there are currently no inspections, or at best they are self-reported, of nicotine levels in e cigarettes. Vaping devices have a variety of ingredients and nicotine levels with anything revealed at the discretion of the manufacturer.
11. 11 E CIGARETTE ORDINANCEISNECESSARY. Tobacco and/or vaping companies currently report nicotine strengths in several ways. They may choose to utilize the number of milligrams in a solution. More often they self-report the percentage of nicotine in their e juice. Less likely is the use of descriptors such as low, medium, and high. As each company chooses how and what to report to the public, there is little correspondence between descriptors and milligrams or percentage of nicotine across brands, which makes standardization impossible. Instead, researchers have created a strength testing in order to report. Complicating this is the sheer volume of brands and flavors. There are currently 466 e cigarette brands and 7764 unique flavors. In addition to this number there are “mix charts” that many companies are promoting now. Furthermore independent “vape shops” can order their own chemicals and create their own unique mixtures. (Zhu, 2014) Older brands* (N=251) Newer brands† (N=215) Older vsnewer brands p value Top-5 brands (N=5) Other brands (N=246) Top-5 vs others p value Older brands combined (N=251) Newer brands (N=215) # of flavors per brand Mean 30 32 0.93 32 49 <0.01 Median 8 15.5 15 33 # of nicotine strengths Mean 5.4 4.4 0.13 4.5 4.4 0.65 Median 5 4 4 5 Zero nicotine offered 80.0% 84.1% 0.85 84.1% 81.9% 0.55 Figure 3: A comparison of flavors and nicotine strengths offered by the 466 e cigarette brands, 2014 Goniewicz, et al (2012) found significant differences between labeled and true levels of nicotine in cartridges and refill solutions. Traces of nicotine were also detected in one of two cartridges labeled as containing no nicotine. These findings indicate that information about
12. 12 E CIGARETTE ORDINANCEISNECESSARY. nicotine levels provided on product packages may be misleading to customers. (Goniewicz, Kuma, Gawron, Knysak, & Kosmider, 2012) With no truth in advertising, the buyer must beware. When a product is being touted as a cessation device and there is no regulation, who ensures that the consumer is actually not harmed by the product? Several studies are already looking into the efficacy of e cigarettes as cessation tools. False Advertising as Cessation Devices A review of the literature related to e cigarettes being used as smoking devices shows that most individuals who use them are attempting to quit smoking traditional cigarettes. (Grana & Ling, 2014) Science is not backing them up however. So far studies of their effectiveness for cessation have been unconvincing. (Bullen 2013 & Caponnetto, 2013) One randomized trial comparing e cigarettes with and without nicotine with a nicotine patch found no differences in 6-month quit rates. (Bullen, 2013) Population-based, longitudinal studies have also not shown associations between e- cigarette use and quitting. (Adkison, 2013 & Vickerman, et al, 2013) One longitudinal study found that, although 85% of smokers who used e cigarettes reported using them to quit, e- cigarette users did not quit more frequently than nonusers (P = .52). Additionally, data from US quit line call centers shows that e cigarette users were less likely to have quit at 7 months than nonusers. (Vickerman, et al, 2013) Unfortunately, many smokers, turning to e cigarettes for cessation help, become dual users. In a study consisting of 19,441 participants, it was found that 3682 participants were in this category. All of them managed to reduce their cigarette use from 20 or more to 4, but their use
13. 13 E CIGARETTE ORDINANCEISNECESSARY. of e cigarettes compensated for the amount of nicotine they were consuming. Participants utilized the e cigarettes in public and around family members with the assumption that it was a healthier alternative. (Farsalinos, Romagna, & Voudris, 2015) The variability of nicotine in e juice also complicates smoking cessation through e- cigarettes. While some e juice purportedly has little to no nicotine, many exceed the amount found in a traditional cigarette. For smokers used to a certain level of nicotine, this can cause increased nicotine addiction rather than aiding in a quit attempt. With no current regulatory services provided, the use of e cigarettes as a cessation tool is far from fool-proof. (Cobb, Hendricks, & Eissenberg, 2015) Additionally, e cigarettes are not approved by the FDA as a smoking cessation device at this time. The FDA is currently deliberating on how to classify e cigarettes and e juice. However, as there is no standardized ingredients in e juice and science has not yet proven the efficacy of e cigarettes as a cessation tool, it is completely unreliable to state that e cigarettes are a cessation tool at this time. (FDA, 2013) Second-hand Vapor The use of electronic devices to inhale e juice provides a vapor that is exhaled much like traditional cigarettes. This vapor has been proven to contain nicotine and other toxic contaminants (Czogala, et al 2014 & Ballbè, et al 2014) though at a lower level than traditional cigarettes. However, recent e cigarette studies showing that there are substantial levels of nanoscale particles in addition to detectable levels of metals with toxic materials (e.g., aluminum, copper, magnesium, zinc, lead, chromium, manganese, and nickel) in e cigarette vapors brings this view into question (Williams, Villarreal, Bozhilov, Lin, & Talbot, 2013). At
14. 14 E CIGARETTE ORDINANCEISNECESSARY. the nanoscale size, particles may reach the alveolar epithelium and mediate oxidative stress and inflammation. Studies continue to analyze the affect that second and even third-hand vapor have on bystanders. The vaping community meanwhile not only purports the vapor to be safe, but is creating a sensationalized sport around it. (Mickle, 2015) Called “cloud chasing” by participants, the sport encourages the largest vapor cloud possible to be released with prizes going to the winner. Nicotine Poisoning in Children Poison control centers have been receiving an increasing number of calls related to nicotine poisonings from e juice exposure. The majority of those harmed have been under the age of six years. (American Association of Poison Control Centers, 2015) In 2015, as of May 31, 2015, the AAPCC has received 1,499 e cigarette devices and liquid nicotine reported exposures. Sixty milligrams of nicotine is enough to kill a 150-pound adult. This causes great concern because some e juice formulas pack as much as 72 milligrams per refill. (Lazutka, Vasilyauskene, & Gefen, 1969) Nicotine poisoning does not require much exposure in youth. Due to their smaller weight and size, toddlers can suffer poisoning at approximately 1 mg/kg in children. (Dart, 2004) These products can contain fatal levels of nicotine for children, who may mistake the e juice for candy or a drink. Nicotine has been theorized to harm adolescence brain development. Pregnant women should also be concerned due to evidence that nicotine can harm fetal brain and lung development. According to the Minnesota Department of Health, “The teen years are a critical
15. 15 E CIGARETTE ORDINANCEISNECESSARY. time for brain growth and development. As a result, adolescents are especially at risk from the harms caused by nicotine exposure. Evidence suggests that exposure to nicotine during adolescence may have long-term effects on brain development. This could have negative implications for human adolescent learning, memory, attention, behavioral problems and future addiction.” (England, 2015) Electrical Mishaps Electrical fires are possible when using e cigarettes. Electronic cigarettes and vaporizers are mainly composed of lithium batteries. There have been reports of explosions of batteries, caused either by prolonged charging and use of improper chargers or by design defects. These have been linked to house fires as well as personal injuries in many national newspapers. (ABC Eyewitness News, 2015) Renormalizing of Smoking Perhaps the greatest public health concern in e cigarettes is the potential for renormalizing smoking in a new generation. (Stanwick, 2015) Currently, the first generation are growing up that never had to sit in a non-smoking section when visiting a restaurant. They will also never have to deal with clouds of second hand smoke when they reach the age to legally enter a bar. Years of education and the normalization of smoking as an unhealthy activity have given rise to the first National Adult Tobacco Survey (NATS) in which the 18-24 segment was the lowest in the nation. (CDC, 2015) This trend continued in middle- and high-school age students. However, the use of e cigarettes escalated dramatically. Burnell, et al (2014) synthesized the 2013 National Youth Tobacco Survey data and found that between 2011-2013, the number of teens who used e cigarettes even one time increased
16. 16 E CIGARETTE ORDINANCEISNECESSARY. three-fold, from 79,000 to over 263,000. Amongst those teens who had tried or were current users of e cigarettes the intention to transition to conventional cigarettes was 43.9%. (38) The 2014 National Youth Tobacco Survey reveals that current e cigarette use among high school students increased from 4.5 percent in 2013 to 13.4 percent in 2014. This shows an astronomical rise in use from approximately 660,000 to 2 million students. Middle school students had similar numbers, tripling from 1.1 percent in 2013 to 3.9 percent in 2014 (increasing from 120,000 to 450,000 students.) This was the first time collecting that current e cigarette use has surpassed current use of any other tobacco product, including conventional cigarettes. (CDC, 2015) Combining this data shows that an increasing number of middle-and high-school students are using e cigarettes. 43.9% of those using e cigarettes are self-disclosing an intent to utilize traditional cigarettes. The path from e cigarette use to traditional smoker becomes very plain. Marketing to Youth A distinct lack of regulation has allowed e cigarette vendors and vaping companies to advertise through every medium as long as they do not claim them as cessation aids. (These claims come through news articles, personal testimonies, and other social media sites.) Using Neilson data, Duke, et al (2014) found that youth exposure to television e cigarette advertisements increased 256% from 2011 to 2013. Young adult exposure increased by more than 300% as well. Additionally, more 3/4 of all youth e cigarette advertising occurred on cable networks frequented by teens and young adults. (Duke, 2014)
17. 17 E CIGARETTE ORDINANCEISNECESSARY. Having access to television advertising, e cigarette companies reach 24 million youth with their products. Unfortunately, there currently exists little evidence-based public health messaging. This allows e cigarette television advertisements to promote harmful beliefs and present behaviors that pose harm to the public health. A report published in 2014 by eleven members of Congress investigated the targeted marketing of e cigarettes to youth through written responses provided by nine popular e- cigarette companies. It was concluded that marketing to adolescents is prevalent, although e- cigarette manufacturers claim they are not targeting this population. Other findings of this report included: Eight e cigarette companies promote their products through sponsored or sampling events, many of which appear to be youth-oriented. In 2012 and 2013 alone, six of the surveyed companies sponsored or provided free samples at 348 events. Seven e cigarette companies air television and radio advertisements during events and programs, including those with youth viewership. Blu’s commercials “have aired thousands of times at various times of the day and night on 48 networks,” and NJOY has advertised during programs including the Super Bowl, an event that reaches a substantial audience of youth under age 18. Six e cigarette companies market e cigarettes in flavors that could appeal to children and teens. For example, e cigarette manufacturers are marketing flavors like Cherry Crush, Chocolate Treat, Peachy Keen, and Grape Mint. E cigarette manufacturers have significantly increased marketing spending, more than doubling expenditures between 2012 and 2013. In total, six e cigarette
18. 18 E CIGARETTE ORDINANCEISNECESSARY. companies spent $59.3 million in 2013 to market e cigarettes. (Williams, & Knight, 2015) E cigarette manufacturers are using the same strategies to market their product as tobacco companies have used for traditional cigarettes in decades past prior to regulations on marketing, including associating vaping with sports and cultural sponsorship, obtaining celebrity endorsement, and through social networking, online advertising, Point of Sale (POS) displays, pricing strategies, and product innovation (See example in Figures 4). (Bunnell, 2014) Figure 4: Comparison of Traditional Tobacco Advertisement with Current E cigarette Advertisement. This advertising is backed by stylish design, glamour, and association with celebrity and fashionable venues and events (such as the Academy Awards), and sponsorship at sporting events (such as the Super Bowl) where free samples are often given out. Major e cigarette manufacturers are targeting young people by giving away free samples at music and sporting events and running radio advertisements during youth-oriented programs. (Tavernise, 2014)
19. 19 E CIGARETTE ORDINANCEISNECESSARY. E cigarette manufacturers may claim that e cigarettes are a safer and cheaper method to satisfy a nicotine addiction; a “healthier alternative,” and “harmless.” E cigarettes may also be promoted as “an indispensable tool in the pathway to quitting smoking.” Marketing of this product promotes long term use as a permanent alternative to tobacco and “the freedom to enjoy the personal pleasures associated with smoking in places where conventional smoking has been banned. (Bunnell, 2014) The Need for Laws, Ordinance, & Policy surrounding E cigarettes E cigarettes are currently not regulated by federal law. Many states have begun regulating e cigarette sale, taxation, and use through state law. Additionally, cities are also free to create their own ordinance to further regulate the sale and use of e cigarettes. Passing legislation regarding e cigarettes must include a detailed look at how they are defined under said law. Current state and city legislation have successfully included e- cigarettes under existing laws that regulate cigarettes. Legal considerations for e cigarettes include sales and marketing restrictions, youth access, smoking restrictions and taxation. Opponents to regulation often push for exceptions to be made in e cigarette legislation. Public health officials oppose these understanding that exceptions for e cigarettes in smoke- free laws may encourage dual users of e cigarettes and conventional cigarettes. Totally exempting e cigarettes from smoke-free laws exposes the public to e cigarette vapor and exposes youth to the norming effect of witnessing “smoking” indoors. Crafting e cigarette law is complicated by the wide variety of terms the industry utilizes. Similar devices may be called e cigarettes, e-hookah, vape-pens, hookah pens and personal
20. 20 E CIGARETTE ORDINANCEISNECESSARY. vaporizers. Adding to this confusion are the hundreds of types and brands of e cigarettes and the ability of users to modify or build their own products. (Grana, Benowitz, & Glantz, 2014) In 2010, a court case found that e cigarettes could not be regulated by the FDA unless they are ‘marketed for therapeutic purposes.’ Further, the FDA could not regulated e cigarettes or e juice as tobacco products unless the FDA eventually finds them to be ‘tobacco products’ under the Family Smoking Prevention and Tobacco Control Act (FSPTCA). (Kirshner, 2011) To date the FDA is still investigating the matter. In April 2014, the FDA issue a preliminary ruling to bring e cigarettes under their tobacco authority. This ruling did not come to fruition however. Currently there exists no federal ruling or stance on e cigarettes. Many states and local communities have been enacting legislation to regulate the use and sale of e cigarettes. (FDA, 2014; National Conference of State Legislatures, 2014; &- American Nonsmokers’ Rights Foundation, 2014) Since they arrived on the market, e cigarette and tobacco companies have been actively promoting legislation designed to serve industry interests. (Family Smoking Prevention and Tobacco Control Act, 2009; Eggert, 2014; McGrory, 2014; Bandyk, 2013) Lobbyist push for laws that exclude e cigarettes from the definition of ‘tobacco product’ or create new definitions for e cigarettes in order to purposefully separate them from current legislation surrounding other tobacco products This forces new law-making for e cigarettes, which is a more lengthy process. Public health advocates and health conscious lawyers seek laws that explicitly define e- cigarettes as ‘tobacco products’ or define ‘smoking’ to include e cigarettes. These laws will better protect health as they automatically subject e cigarettes to the same laws and regulations
21. 21 E CIGARETTE ORDINANCEISNECESSARY. as conventional cigarettes without additional legislation. Future laws need to broadly define e- cigarettes to include future modifications and terminology that will come from the industry as well. Conclusion E cigarettes and their corresponding e juice present a clear public health hazard. The best arguments for their use include justifications including “acceptable limits of toxicity” and raise questions regarding how much carcinogens are acceptable in children. Legislation is the only way to ensure the tobacco and vaping companies adhere to whatever is agreed upon by the FDA as acceptable use. Just as traditional cigarettes were regulated at the federal level, e cigarettes need guidelines for production. Current e cigarettes have exploded due to faulty wiring and batteries causing physical harm and property damage. E juice can be created in the back of a vape shop allowing for untold numbers of contaminants to be included. The refillable liquids shipped from manufacturers has been found to contain varying amounts of nicotine. Public safety demands a legal definition that can be used to uphold the citizens’ right to health. If legislation does not get out in front of e cigarettes, history will follow that of American anti-smoking laws. How many died of lung cancer and other disease before the Surgeon General’s first report on smoking? What percentage of our youth is an acceptable loss to nicotine addiction before e cigarettes are regulated?
22. 22 E CIGARETTE ORDINANCEISNECESSARY. References ABC Eyewitness News (2015) “E CIGARETTE LODGES INTO CEILING AFTER EXPLODING IN SANTA ANA MAN'S HANDS” Retrieved from: cigarette-lodges-into-ceiling-after-exploding-in-oc-mans- hands/551894/ Adkison, S. E., O'Connor, R. J., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H. H., & Fong, G. T. (2013). Electronic nicotine delivery systems: international tobacco control four-country survey. American journal of preventive medicine, 44(3), 207-215. American Association of Poison Control Centers (2015) “E cigarette Devices and Liquid Nicotine” Retrievedfrom: cigarettes/ American Nonsmokers’ Rights Foundation. U.S. State and Local Laws Regulating Use of Electronic Cigarettes. 2014. cigslaws.pdf (accessed 10 Jul 2014). Ballbè, M., Martínez-Sánchez, J. M., Sureda, X., Fu, M., Pérez-Ortuño, R., Pascual, J. A., & Fernández, E. (2014). Cigarettes vs. e cigarettes: Passive exposure at home measured by means of airborne marker and biomarkers. Environmental research, 135, 76-80. Bandyk M (2013). Big Tobacco Stubs out E cigarette Competitors. Retrieved from: cigarette-competitors/ (accessed 10 Jul 2014). Barbara Demick (25 April 2009). "A high-tech approach to getting a nicotine fix". Los Angeles Times
23. 23 E CIGARETTE ORDINANCEISNECESSARY. Bullen, C., Howe, C., Laugesen, M., McRobbie, H., Parag, V., Williman, J., & Walker, N. (2013). Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet, 382(9905), 1629-1637 Bunnell, R. E., Agaku, I. T., Arrazola, R., Apelberg, B. J., Caraballo, R. S., Corey, C. G., & King, B. A. (2014). Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013. Nicotine & Tobacco Research, ntu166. Cobb, C. O., Hendricks, P. S., & Eissenberg, T. (2015). Electronic cigarettes and nicotine dependence: evolving products, evolving problems. BMC medicine, 13(1), 119. Caponnetto, Pasquale; Campagna, Davide; Papale, Gabriella; Russo, Cristina; Polosa, Riccardo (2012). "The emerging phenomenon of electronic cigarettes". Expert Review of Respiratory Medicine 6 (1): 63–74. doi:10.1586/ers.11.92.ISSN 1747-6348. PMID 22283580. Caponnetto, P., Campagna, D., Cibella, F., Morjaria, J. B., Caruso, M., Russo, C., & Polosa, R. (2013). EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PloS one, 8(6), e66317. CDC: Health Effects of Cigarette Smoking. Retried July 20, 2015 from: CDC (2015) “Current Cigarette Smoking Among Adults in the United States” Retrieved from: tm#national
24. 24 E CIGARETTE ORDINANCEISNECESSARY. CDC (2015) “E cigarette use triples among middle and high school students in just one year.” Retrieved from: cigarette-use.html CDC (2015) Current Cigarette Smoking Among Adults—United States, 2005–2013.. Morbidity and Mortality Weekly Report 2014;63(47):1108–12 [accessed 2015 Jan 22]. Cheng, T. (2014). "Chemical evaluation of electronic cigarettes". Tobacco Control 23 (Supplement 2): ii11–ii17. doi:10.1136/tobaccocontrol-2013-051482. ISSN 0964-4563. PMC 3995255. PMID 24732157 Czogala, J., Goniewicz, M. L., Fidelus, B., Zielinska-Danch, W., Travers, M. J., & Sobczak, A. (2014). Secondhand exposure to vapors from electronic cigarettes. nicotine & tobacco research, 16(6), 655-662. Dart RC (2004). Medical toxicology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. pp. 601–604. ISBN 9780781728454. Department 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, 1998 [accessed 2015 Mar 26]. Duke, J. C., Lee, Y. O., Kim, A. E., Watson, K. A., Arnold, K. Y., Nonnemaker, J. M., & Porter, L. (2014). Exposure to electronic cigarette television advertisements among youth and young adults. Pediatrics, 134(1), e29-e36. England, L. J., Bunnell, R. E., Pechacek, T. F., Tong, V. T., & McAfee, T. A. (2015). Nicotine and the Developing Human. Am J Prev Med, 1.
25. 25 E CIGARETTE ORDINANCEISNECESSARY. Ebbert, Jon O.; Agunwamba, Amenah A.; Rutten, Lila J. (2015). "Counseling Patients on the Use of Electronic Cigarettes". Mayo Clinic Proceedings 90 (1): 128–134. doi:10.1016/j.mayocp.2014.11.004. ISSN 0025-6196. PMID 25572196. Eggert D. (2014) Why Snyder May Veto E cigarette Bills That Would Prohibit Sale to Minors (22 June). 2014. michigan-electronic-cigarettes (accessed 10 Jul 2014). Fairchild, A. L., Bayer, R., & Colgrove, J. (2014). The renormalization of smoking? E cigarettes and the tobacco “endgame”. New England Journal of Medicine, 370(4), 293-295. Family Smoking Prevention and Tobacco Control Act, Sect. 916, P.L. 111–31 (22 June 2009). Farsalinos, K. E., & Polosa, R. (2014). Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Therapeutic advances in drug safety, 5(2), 67-86. Farsalinos, K. E., Romagna, G., & Voudris, V. (2015). Factors associated with dual use of tobacco and electronic cigarettes: A case control study. International Journal of Drug Policy. FDA “FDA Warns of HealthRisksPosedbyE cigarettes”(ReviewedSept.17, 2013) Retrievedfrom: 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
26. 26 E CIGARETTE ORDINANCEISNECESSARY. Warning Statements for Tobacco Products; Proposed Rule, April 25, 2014. 79 FR 23141. 2014. Goniewicz, M. L., Knysak, J., Gawron, M., Kosmider, L., Sobczak, A., Kurek, J., & Benowitz, N. (2014). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco control, 23(2), 133-139. Goniewicz, M. L., Kuma, T., Gawron, M., Knysak, J., & Kosmider, L. (2012). Nicotine levels in electronic cigarettes. Nicotine & Tobacco Research, nts103. Grana, R. A., & Ling, P. M. (2014). “Smoking revolution”: a content analysis of electronic cigarette retail websites. American journal of preventive medicine, 46(4), 395-403. Grana, R., Benowitz, N., & Glantz, S. A. (2014). E cigarettes a scientific review. Circulation, 129(19), 1972-1986. Lazutka FA, Vasilyauskene AD, Gefen SG . Toxicological evaluation of the insecticide nicotine sulfate. Gig Sanit 34(5):30-33 Kirshner, L. (2011). RECENT CASE DEVELOPMENTS: DC Circuit Rules FDA Cannot Block E cigarette Imports--Sottera, Inc. v. FDA 1. Am. JL and Med., 37, 194-652. Maguire M. North Carolina Lawmakers Adopt Tax on Electronic Cigarettes (29 May).2014. idUSL1N0OF22R20140529 (accessed 10 Jul 2014).
27. 27 E CIGARETTE ORDINANCEISNECESSARY. McGrory K (2014). Anti-Smoking Groups Work to Kill E cigarette Bill in Florida (7 Apr). 2014. kill.html(accessed 10 Jul 2014). Mickle, T. (2015) “Take a Deep Breath if You Want to Try Competitive Vaping” Retrieved from: vaping-1429646394 National Conference of State Legislatures. Table of State Actions Concerning Alternative Nicotine Products/Electronic Cigarettes. 2014. Pepper, J. K.; Brewer, N. T. (2013). "Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review". Tobacco Control 23 (5): 375– 384. doi:10.1136/tobaccocontrol-2013-051122. ISSN 0964-4563. PMID 24259045. P.H. (17 March 2014). "A case of the vapers". The Economist. Tavernise S. (2014) E cigarettes Are Targeted at Youths, Report Says. New York Times. 2014 Apr 14;:2014. Stanwick, R. (2015). E cigarettes: Are we renormalizing public smoking? Reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in Canada. Paediatrics & child health, 20(2), 1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for
28. 28 E CIGARETTE ORDINANCEISNECESSARY. Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2014 Feb 6]. U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, Hispanics: A Report of the Surgeon General. Atlanta, Georgia: U.S. Vickerman KA, Carpenter KM, Altman T, Nash CM, Zbikowski SM. (2013) Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine Tob Res. 2013;15(10):1787-1791. Weaver, Michael; Breland, Alison; Spindle, Tory; Eissenberg, Thomas (2014). "Electronic Cigarettes". Journal of Addiction Medicine 8 (4): 234–240. doi:10.1097/ADM.0000000000000043. ISSN 1932-0620. PMID 25089953. Williams, M., Villarreal, A., Bozhilov, K., Lin, S., & Talbot, P. (2013). Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. Williams, R. J., & Knight, R. (2015). Insights in Public Health Electronic Cigarettes: Marketing to Hawai ‘i's Adolescents. Hawai'i Journal of Medicine & Public Health, 74(2), 66. World Health Organization (WHO) WHO says there is no evidence that the electronic cigarette helps smokers to quit smoking. WHO this week asked manufacturers and marketers to stop their unproved therapy claims. Transcript of WHO podcast. Geneva, Switzerland: [accessed 2 Oct 2012]. Sep 26, 2008.
29. 29 E CIGARETTE ORDINANCEISNECESSARY. Zhu, S. H., Sun, J. Y., Bonnevie, E., Cummins, S. E., Gamst, A., Yin, L., & Lee, M. (2014). Four hundred and sixty brands of e cigarettes and counting: implications for product regulation. Tobacco control, 23(suppl 3), iii3-iii9. .
30. 30 E CIGARETTE ORDINANCEISNECESSARY. Core Competencies Courses, Conferences, Master’s Paper (MP), Practicum (P) Narrative 1.1 Biostatistics: Distinguish among the different measurement scales and the implications for selection of statistical methods to be used based on these distinctions. MPH 731, P Hands-on training with SPSS software. Coursework provided the basis of understanding. My practicum included a survey in which I had to calculate the appropriate statistics for use in developing effective policy. 1.2 Biostatistics: Interpret results of statistical analyses found in public health studies. MPH 731, 751, MP, P Interpreting the data from my survey allowed for policy work to be done. Researching my paper required effective interpretation of population statistics regarding health markers and harmful behavior. 2.1 Epidemiology: Describe a public health problem in terms of magnitude, person,time and place. MPH 751, MP Readings; weekly assignments; In my paper I researched heavily how e cigarettes are affecting youth in an escalating manner over the last three years. 2.2 Epidemiology: Calculate basic epidemiological measures. MPH 751 Outside of classwork I was able to utilize either SPSS or other software to calculate needed epidemiological data that I input. Learning about GIS during our class helped me with this. 3.1 Health Policy and Management: Identify the organization, financing, and delivery issues ofthe health service systemin the US. MPH 710, HNES 725, 745 Through my classes I learned how US health care is primarily reactionary and how we can work towards becoming a prevention model of health care. 3.2 Health Policy and Management: Describe the legal, ethical, historical, and philosophical bases for the health service delivery systemin the U.S. MPH 704, 710, HNES 725, MP Through classwork and research in those classes I explored the legality and ethics of health services. In my MP I narrowed that down to researching current tobacco and e- cigarette law.
31. 31 E CIGARETTE ORDINANCEISNECESSARY. Core Competencies Courses, Conferences, Master’s Paper (MP), Practicum (P) Narrative 3.3 Health Policy and Management: Discuss the policy process for improving the health status of populations. MPH 704, HNES 721, 725, 745, P, MP All of my classes discussed this to a degree. In my practicum and MP I address how e cigarettes affect the health status ofall, particularly youth. 3.4 Health Policy and Management: Apply “systems thinking” for resolving organizational problems. MPH 704, 710, P, HNES 721, 725, 745, P, MP Developing my practicum and MP I looked at the big picture of laws and ordinance, how we can change the environment as well to promote healthy changes. 3.5 Health Policy and Management: Analyze public health challenges within appropriate ethical and legal frameworks MPH 704, HNES 725, 745, MP My MP really dives into the ethics surrounding legislation of e- cigarettes. 4.1 Social and Behavioral Sciences:Identify basic theories, concepts and models from a range of social and behavioral disciplines that are used in public health research and practice. MPH 741, HNES 725, P, MP The social ecological model is used in both my P and MP. Educating the individual is good, but I move up the scale to community, state, and national change. 4.2 Social and Behavioral Sciences:Identify and analyze the social and behavioral factors that affect health of diverse populations. MPH 741, P, MP, HNES 721, 725, 724, 727, 745 My classwork laid the groundwork for this method of thinking. I do address it in my P and MP, but I feel in my position as Tobacco Coordinator for Clay County I address these issues every day. 4.3 Social and Behavioral Sciences:Describe the role of social and community factors in both the onset and solution of public health problems. MPH 741, HNES 721, 724, 725, 745, P, MP I delve deeply into social factors such as the media targeting youth to promote e cigarette use in my MP. 5.1 Environmental Health: Describe the direct and indirect human, ecological and safety effects of major environmental and occupationalagents. MPH 720, HNES 725, MP Classwork covered traditional environmental concerns. In my HNES classes we blew up the concept of environment to include social norms as environment. I discuss these greatly in my MP. 5.2 Environmental Health: Discuss various risk management and risk communication MPH 720, HNES 725, P Continuing from above,in my practicum I conducted a survey of
32. 32 E CIGARETTE ORDINANCEISNECESSARY. Core Competencies Courses, Conferences, Master’s Paper (MP), Practicum (P) Narrative approaches in relation to issues of environmental and occupationaljustice and equity. business owners in which I speak to the justice of environmental harms (e cig vapor) being allowed in both their place of business and their city. 6.1 Communication: Develop effective communication skills in writing and speaking, in person,and through electronic means. MPH 704, 731, 741, 751, P, MP, HNES 721, 725, 745 Every class I have taken included written communication. Most of those listed also required presentations. My practicum included creation of video presentations. 6.2 Communication: Solicit community- based input from individuals and organizations. P I have created and conducted a survey in a community in Minnesota. 6.3 Communication: Participate in the development of demographic, statistical, programmatic and scientific presentations. MPH 704, 731, P, MP, HNES 721, 725, 745 My classwork prepared me for my practicum and MP in which I had to gather these forms of data and present them. 6.4 Communication: Demonstrate written and oral communication skills that express sensitivity to diverse socioeconomic, cultural, and demographic subgroups. MPH 710, 720, P, MP, HNES 721, 725, 745 Cultural sensitivity and competency is a component of public health work and as such was practiced in all of my classes. Health Promotion Competencies HP 1. Comprehend and apply the principles of behavioral change models, theories, and practices throughout the process ofneeds assessment,program development, implementation, and evaluation to improve the health of populations. HNES 721, 724, P, MP Weekly readings and discussion papers; weekly discussion/focus groups on the topics.Semester based projects allowed application of the material. Beyond my classroom work, I apply this knowledge in developing my practicum’s survey and deliverables. This work is part of a plan that will develop into a meeting with the city council advocating for Clean Indoor Air policy for their city.
33. 33 E CIGARETTE ORDINANCEISNECESSARY. Core Competencies Courses, Conferences, Master’s Paper (MP), Practicum (P) Narrative HP 2. Utilize interdisciplinary public health information, including epidemiology and biostatistics to analyze and explain health problems and issues facing communities. HNES 721, 727, P, MP Weekly readings and discussion papers; weekly discussion/focus groups on the topics.Semester based projects allowed application of the material. My practicum work has this being done behind the scene and involves gathering some of this data for future work. My MP utilizes this information to direct a narrative on why legislation and/orpolicy is the best way to change the environment and provide a system of change in the community, state, and nation. HP 3. Develop and evaluate comprehensive, evidence-based strategies to improve individual health by promoting health through policy, system, and environmental change at organizational and community levels. HNES 721, 725, 727, P, MP, Day at the Capitol (Tobacco Policy) Weekly readings and discussion papers; weekly discussion/focus groups on the topics.Semester based projects allowed application of the material. Including the previous statements,my work with this material in class led to my appointment in Clay County Public Health. Daily I use the work that I learned here. Part of my position is the development of PSE changes in 4 MN counties and the advocating for the same at the State level. HP 4. Explain and utilize leadership skills to build collaboration with the purpose of improving the health of the community. HNES 724, 725, 745, P, MP Weekly readings and discussion papers; weekly discussion/focus groups on the topics.Semester based projects allowed application of the material. Group projects also allowed leadership within peers. My practicum will lead to conversation with the city council of a MN community. My MP will be read and possibly utilized by all of the anti-tobacco agencies in MN from MDH down to the county
34. 34 E CIGARETTE ORDINANCEISNECESSARY. Core Competencies Courses, Conferences, Master’s Paper (MP), Practicum (P) Narrative level. My position as Tobacco Coordinator allows me to use the skills I learned through my MPH program to create partnerships in the cities and counties that I serve.