Monday, March 7, 2016

Battle over e-cigarettes

I was recently asked to create a report on e-cigarettes by a friendly company. Some of the workers started complaining about secondhand e-cigarette vapor. The discussion got heated up because five pregnant women were working at the open space office where the vapers were located. The HR did some preliminary research and sent out an email with new rules. They said that e-cigarettes were more carcinogenic than traditional cigarettes and that WHO advised to prohibit vaping at workplace because of the threat of secondhand vapor. Vaping got banned.

This resulted in a backlash and some vapers ended up writing long emails on how this is all untrue. They cited sources like NHS as well as scientific papers supposedly debunking claims made by HR. Nevertheless the management decided that the ban on e-cigarettes was here to stay. In the meanwhile they asked me about my opinion.

In a nutshell, e-cigarettes are most likely much less harmful than traditional cigarettes. They do not contain most harmful substances released by burning tobacco. The amounts of other supposedly harmful substances in the secondhand vapor may be lower than in other products happily ingested or inhaled by people (including pregnant women). There exist no scientific proof that e-cigarettes are toxic to bystanders.

E-cigarettes are indeed a different product than traditional cigarettes and the comparisons of the two are unjustified. Their sin is that they share the name, a single ingredient (nicotine), and the consumption looks similar to that of the super-villain traditional cigarettes. Guilt by association on one hand and the interest groups on the other hand contribute to fearmongering about these products. As a result, e-cigarettes in the eyes of public are guilty until proven innocent.

Nevertheless, there is a small risk that the exhaled vapor contains amounts of nicotine high enough to damage or otherwise hamper the development of a fetus. Pregnant women should have the right to be protected from exposure to vapor, until research shows that e-cigarettes are safe for fetal development. In general, regular adults should have the right to breathe air that is not contaminated by emissions of other people, be it cigarette smoke, scented candles, body odor, farts, or vapor. In the same way visual and sonic pollution of common spaces are often limited.

In the context of office environment, vaping should be thus prohibited if coworkers strongly request so. Since there is currently no definite scientific evidence either way, a firm can decide to do whatever maximizes the profit. If vaping reduces productivity by making workers unhappy, it should be banned. If it increases productivity by eliminating cigarette breaks, then it should be allowed. As for the litigation, it is unlikely that the plaintiff can succeed in suing a company for exposing them to a secondhand vapor because there is no scientific proof that it is harmful. It is more likely that vapers succeed in suing a company that confined them to a space occupied by regular smokers, since the tobacco smoke is proven to be harmful.

All these ideas will be developed in detail in what follows. Let us start with nicotine.


Nicotine is addictive. This in itself is not bad for the health of an individual. The only well-established risk associated with intake of nicotine is increased chance of developing cardiovascular disease. But, since nicotine is the addictive component of tobacco, it is the sworn enemy number one of many health officials. Thus, much more effort is done to prove its harmfulness than to disprove it or to prove its benefits. Scientific papers on benefits of nicotine always underline that it is also harmful but scientific papers on its disadvantages (much more numerous) hardly ever mention any benefits at all. This is a signal that scientific community is not objectively analyzing the issue. Nevertheless, despite all the effort, few adverse effects of nicotine are confirmed.

There is a number of theories linking use of nicotine to malfunction of various systems in the body. Most notably, nicotine is often linked to cancer or fetal problems. These two claims are however made up on the basis of guilt by association – they are proven results of smoking which involves inhalation of many other substances. Clinical trials with nicotine replacement therapy do not confirm any of these claims. As one influential study says: “The safety of NRT in terms of effect on fetal development and birth outcomes remains unclear in pooled data from this review.”

The current scientific knowledge indicates that if the dose is right, the effects of nicotine on human body are similar to those of caffeine. The only difference is that nicotine is more addictive.

The difference between cigarettes and e-cigarettes

Smoking cigarettes involves inhaling smoke generated during combustion of tobacco leaves. Some studies try to prove that chemical composition of tobacco makes its smoke especially carcinogenic, but the truth is that any regular smoke has a lot of carcinogenic substances. Smoked food has been identified as a cause for cancer (fried food as well). Any other smoke, including smoke from chimneys, cannabis, scented candles, or car exhaust fumes (especially diesel) also contains carcinogens. Two main factors influence how carcinogenic it is: (1) dirtiness of the smoke – low temperatures and limited oxygen can contribute to incomplete combustion leaving many reactive particles intact and (2) the amount of smoke inhaled – definitely higher in case of smoke produced exclusively for the purpose of inhaling it multiple times a day.

On the other hand, the aerosol (often called vapor) generated by e-cigarettes is not a result of combustion. A part of e-cigarette called atomizer increases the temperature of the e-liquid causing it to turn into aerosol. As a result, there is no change in the chemical composition of the ingredients (unless there is contamination).

Cigarette smoke contains thousands of different substances, many of which are identified as harmful, either as carcinogens or otherwise. E-cigarette aerosol do not contain these substances. Chemical composition of regular cigarette smoke is much closer to the smoke generated by a scented candle or a chimney than to vapor generated by e-cigarettes. It is thus silly to automatically associate e-cigarettes with regular cigarettes because they are used similarly and they have a similar name. They are completely different products with highly separated sets of advantages and disadvantages.

Potential harms of e-cigarettes

Looking for negative effects of e-cigarettes, it is easy to come across lists including items such: (1) lithium-ion batteries of e-cigarettes sometimes explode causing burns, (2) e-liquid can cause poisoning in children who drink it, or (3) adults sometimes confuse e-liquid with another product like eye drops which also causes poisoning. These are ridiculous claims that are not idiosyncratic to e-cigarettes but can be applied to any electronic or chemical product. They are found on such lists not because e-cigarettes are especially prone to such accidents but because anti-e-cigarettes activists try to make them look scarier (this tactic may have an adverse effect as it undermines credibility of the authors in the eyes of a skeptic reader). For the purpose of this analysis I will focus only on the aspects related to inhaling vapor.

The ingredients of e-liquid are most often: propylene glycol, glycerol, water, and nicotine. The first two compounds are widely used in the food industry and are proven to be safe for consumption by humans including pregnant women. In addition, e-liquid often contains flavorings and other additives that depend on the brand of the product. These need to be checked individually for potential adverse effects in the same way flavors and other additives to food products need to be checked.

Some studies indicate that e-liquid may get contaminated and then vapor contains other potentially toxic chemicals, for example heavy metals. It is however important to remember that most of these potentially harmful substances are present virtually everywhere. For example, lead is present both in the air at the top of Mount Everest and in the seawater of Mariana Trench (as a curiosity, lead in seawater is three times as common as gold but a hundred time less commont han uranium). Just the fact that the substance is present does not matter. It matters only if the concentration is high enough to affect human health. And no study has shown that vapor contains harmful quantities of contaminants.

There does not seem to be anything in e-cigarettes that justifies the outcry and fearmongering about its potentially harmful ingredients.

Why people are so wary of e-cigarettes then?

There are four main articles on Wikipedia about e-cigarettes: (1) Electronic cigarette, (2) Safety of electronic cigarettes, (3) Electronic cigarette aerosol and e-liquid, and (4) Positions of medical organizations on electronic cigarettes. Health-related parts of these articles look like battlefields. They consist of intertwined positive and negative statements debunking each other. Almost every sentence has references to scientific sources. The irony is that virtually none of these statements prove anything. Words like “may” or “can” are much more common than “is” or “do.” The overall message (often explicitly expressed at the beginning of an article) is that nobody knows anything. These Wikipedia articles are thus the longest, most elaborate and well-sourced but also entirely meaningless and pointless texts one can ever imagine.

What are the forces that created these battlefields? In one corner there are vapers (who want to vape) and the vaping industry (who want to make profit). In the other corner are concerned citizens, most health organizations (with the notable exceptions of British ones) and politicians. Surprisingly, Big Tobacco – the most obvious potential opponent to e-cigarettes as they constitute competition – does not seem to be a driving force. To the contrary, the Big Tobacco slowly tries to diversify by investing in the e-cigarette industry.

Consider California. Master Settlement Agreement – a deal between 46 US states and the major tobacco companies – provides California (and other states) with a steady stream of money intended to cover medical expanses caused by tobacco use. The source of money are tobacco companies and the amount depends on their sales (a few cents per cigarette). Like other states, California decided to securitize the future payments in order to get more money upfront. This resulted in creation of so called tobacco bonds. Government issues these bonds and the buyers gets repaid with the money government receives over time from tobacco companies.

When the sales of cigarettes are too low and the amount of money is not enough to repay the debt, the bonds are in default. However, since the revenues will continue as long as cigarettes are being sold, the default often means that the creditors will eventually receive their money, although later. Some states (including California) chip in their backing to boost creditworthiness of tobacco bonds. That is they promise they will repay creditors using tax receipts if the money from tobacco companies is not enough.

Because state revenues depend on the amount of cigarettes sold, states have incentive to maintain this source of revenue by, say, banning or taxing e-cigarettes. In addition, securitization created a lobby – people who bought tobacco bonds – whose interest is in maximizing the number of regular cigarettes sold. And the amounts of money we are talking about are not small – by 2007 California has emitted nearly $17 billion worth of tobacco bonds. Various statesare working on banning or taxing e-cigarettes comparably to regular cigarettes, including California. Members of California’s tax commission shamelessly spread bullshit in the documents calling for higher taxation: in a 2015 report Ms. Fiona Ma, in addition to making statements already debunked in this article, writes that: “Tobacco companies claim that E-cigarettes are not as harmful as conventional cigarettes (…). However, these claims are refuted by strong scientific evidence that claims that E-cigarettes can be just as harmful as conventional cigarettes.” What evidence? Unfortunately no sources are provided.

Health organizations

But the worst source of misinformation and fearmongering are health officials and health activists. Let us analyze the 2015 report signed by the then director of the California Department of Public Health. A long litany of concerns regarding e-cigarettes starts with indications than they are more and more popular, especially among young people and many of these young people never smoked cigarettes. These are all true facts. But they are not obviously bad. They would be bad if the overall health of population was declining due to growing trend in consumption of e-cigarettes. And nobody was able to prove that so far. The fact that adolescents who never smoked tobacco use e-cigarettes does not mean anything: maybe these individuals would use regular tobacco products instead, if e-cigarettes were not available.

The report states: “Research suggests that kids who may have otherwise never smoked cigarettes are now becoming addicted to nicotine through the use of e-cigarettes and other e-products.” And then there is a reference to a scientific paper in which we read: “This is a cross-section study, which only allows us to identify associations, not causal relationships.” That is, the study itself says that they do not claim that e-cigarettes cause increase in addiction to nicotine. Whether the authors of the report intentionally lied is hard to say – it seems more likely that they did not read the paper they were citing and their conclusions were influenced by strong confirmation bias. In a nutshell: they did not lie, they were just lazy and biased.

Some additional statements in the report include:
  • Nicotine is highly addictive neurotoxin, especially in adolescents. The report fails to specify that it indeed is harmful to adolescent rats when administered through injection. Trials in humans do not confirm these claims.
  • Vapor is a concoction of toxic chemicals, at least ten of which are known to cause cancer, birth defects, or other reproductive harm. This statement can be equally truthfully made about many types of food we eat daily, e.g. french fries.
  • E-liquid may be confused by children who would eat it; e-cigarettes sometimes leak which can lead to poisoning when e-liquid is ingested or are used as an eye-drop by mistake. Yes, misuse happens with every product. But does it happen more often with e-cigarettes?
  • Claims that e-cigarettes help to quit smoking are unproven. But switching from smoking to vaping precisely is quitting smoking, isn’t it?
  • E-cigarettes are undermining current smoke-shaming norms and provide a way around smoking bans. True, only if you equate smoking with vaping in your mind. Otherwise false.

The overall picture that emerges is as follows. Health officials are under influence of several forces that make them such strong opponents of e-cigarettes:
  • They are often incompetent, biased, and lack critical thinking (traditional human characteristic). They engage in herd behavior – if so many people around me say it, it must be true (traditional human characteristic). They are lazy and do not check other people, especially not those whom they agree with upfront (traditional human characteristic).
  • Their job is to protect population from any health risks (also those overblown or imaginary). They take their task of policing other people and telling them what to do too seriously. They often neglecting aspects other than direct impact on health (economic issues, unintended consequences, etc.).
  • Bashing e-cigarettes is popular because it is easy to associate e-cigarettes with regular cigarettes and the latter are proven to be harmful. They respond to pressures: some people demand bashing e-cigarettes, especially fearful parents.
  • Their views are reinforced by other officials, most notably those responsible for tax revenues.
  • They worked hard to brand smoking as bad and e-cigarettes constitute a new trend that in their eyes threatens this achievement. 

To vape or not to vape?

Now that we have established what the facts are and explained the sources of confusions, it is time to make a decision: to vape or not to vape?

A rational individual should consider both advantages and disadvantages of vaping and chose whatever this cost-benefit analysis indicates. This is hard to do in practice because the ideological warfare reduces the quality of available objective information. For example, the research on the positive effects of nicotine is seriously underdeveloped meanwhile the research on its negative effects if overdeveloped and full of exaggerations.

If you are a smoker, than the answer is simple: stop smoking and start vaping. If you are a non-smoker, there are probably better methods of getting benefits nicotine provides: for example, if you need to get focused, you may consider drinking coffee. But if there are no other ways for you to, say, relieve stress, you may try to see if vaping can help you. Remember to consider how addictive your personality is. Some people get addicted much easier than others. If you belong to the former group, it is riskier for you to experiment with nicotine because you may get addicted even if benefits turn out to be not worth the costs.

But the main objective of this article is to advise a company on a policy. Should HR ban vaping in the company buildings? Things to consider when answering this question are summarized in the table below:

Vaping is allowed in common spaces.
Vaping is not allowed in common spaces.
Health effects on employees.
Non-smokers may be exposed to vapor (which has no proven negative health consequences). Also, people who quit smoking may be exposed to nicotine, which may induce relapse.
Vapers may end up vaping in the same areas as smokers which may be unhealthy to them due to secondhand smoke.
Some workers may consider it irritating or may estimate risk of inhaling vapor to be high. These workers may become less productive. Tensions between workers create unproductive working environment for the entire company.
Vapers take multiple breaks a day to go out. Productivity decreases, although probably not as much – breaks are often needed by workers and would happen anyway but in a hidden way, say by sitting idle next to one’s computer.
Possible lawsuit.
Non-smokers can sue a company for forcing them to be in vicinity of vapers, especially if they ended up having health problems, as in the case of traditional cigarettes. A very unlikely scenario.
Vapers can sue company if they can prove that company rules forced them to be in the vicinity of smokers, especially when they have prescription for e-cigarette or if they develop a disease associated with secondhand tobacco smoke but not with vaping. A very unlikely scenario.

In general, productivity issue seems to be most important. If many employees request a ban, one probably should be enacted. Otherwise not.

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