New e-inhalation products and potential health risks: The case for regulation

10/25/2016
New e-inhalation products and
potential health risks:
The case for regulation
Dr. Martina Pötschke-Langer, Dr. Katrin Schaller
Unit of Cancer Prevention,
WHO Collaborating Centre for Tobacco Control,
German Cancer Research Center (DKFZ)

18.07.2014|
Dr. M. Pötschke-Langer
New e-inhalation products Overview
• The new growing market for electronic inhalation products
• Potential health risks
• The case for regulation

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New e-inhalation products
Electronic inhalation products
1
2 3
4
5 6
Components of an e-cigarette
8
(1) (Rechargeable)
battery
(2) (Manual) switch
(3) Vaporizer
(4) Mouthpiece
(5) Air-permeable
insulating material
(6) Heating coil
(7) Wick
(8) Liquid container
7

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One way e-cigarettes
http://www.riccardo-zigarette.de/Riccardo-Einwegzigarette:::91.html
R200 TT one way e-cigarette
http://www.ttzig.eu/index.php?page=shop.product_de
tails&flypage=flypage.tpl&product_id=1&category_id=
1&vmcchk=1&option=com_virtuemart&Itemid=240

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Refillable e-cigarettes
http://www.red-kiwi.de/products/e-
zigarette-red-kiwi-es-504-t/
http://www.red-kiwi.de/products/e-
zigarette-red-kiwi-rocket-ii-s-line/
red kiwi
Rocket II S-Line
red kiwi
ES-504 T
http://dampferins
el.de/zubehoer/a
kkus/444/ego-
akku-650mah-
strass?c=1238
e cig battery ego-k electronic
http://www.dhgate.com/store/product/colourful-
eGo Akku 650mAh Strass

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New e-cigarette for youth
www.supersmokerbluetooth.de

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http://www.steamo.de/epipe/ http://www.besserdampfen.de/Akkutraeger/1507/Vision-E-Kross http://future-smoke.de/Omar-
FARBEN-MOD-fuer-Ihre-E-
Pfeife-FS852-und-FS852M
http://future-smoke.de/12er-Pack-FS-
Einwegzigarre-V2-FS-Cuban-18-mg
http://www.123e-zigarette.de/E-Zigarre/Profi-e-Zigarette-Elektrische-
Zigarre-E-Zigarre-mit-24-Depots-S::52.html
Pipes and cigars

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www.kaya-shisha.de
• Same principle as e-cigarettes
• Sometimes different mouthpiece
• 500 – 1500 puffs
• Also as refillable pens
http://www.wasserpfeife-shisha.comar
http://www.shisha-dreams.de/E-Shisha/Shisha-EMPIRE-E-
Shisha/Shisha-Empire-E-Shisha-nachfuellbar::2313.html
E-Shisha

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• Mostly without nicotine
• On the internet also availablbe with nicotine
E-Shisha
http://www.hookah-shisha.com/p-13147-starbuzz-e-cig-tobacco-free-electronic-cigarette.html

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http://www.stern.de/digital/homeentertainment/elektronisch-kiffen-vergessen-sie-die-e-zigarette-der-e-joint-ist-da-2119011.html
E-Joint
• No tobacco
• No nicotine
• No THC
• E-Joints with cannabis concentrate
announced by the manufacturer

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Pack design– attractive to youth
Liquids
for e-inhalation products

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Huge range of flavours – attractive to youth
Liquids
Example: E-cigarette liquids
http://www.riccardo-zigarette.de/Riccardo-Liquid:::73.html

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Huge range of flavours - attractive to youth
http://shisha-swag.de/index.php?PHPSESSID=8cf6ac5577d0c9d29e4ad4c3b77a06f0
Liquids
Example:
E-shisha liquids

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Liquids
Ingredients
• Propylene glycol
• Glycerol
• Flavours
• Nicotine
http://flavourart.de/index.php
Potential health risks

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Propylene glycol
© Foto: Bundesamt für Gesundheit (BAG), CH
• Authorized as ”E 1520“ for
oral intake (food additive) and dermal
application (cosmetic) in low dose
• Inhalation: irritation of respiratory
system
• Unknown long-term effect (inhalation)
Refs:
Agency for Toxic Substances and Disease Registry (ATSDR) (1997) Toxicological Profile for Propylene Glycol;
Moline JM et al.(2000) Health effects evaluation of theatrical smoke, haze and pyrotechnics, Report;
Choi H et al., PLoS One 5: e13423; Bundesinstitut für Risikobewertung, Advisory opinion No. 016/2012 of 24 February 2012

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Glycerol
• Authorized as food additive (humectant, stablilizing agent)
• Unknown long-term effect of repeated inhalation

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Flavours
• Some flavours are allergic
(menthol, vanilline, eugenol, linalool,
anis alcohol)
• Unknown long-term effect of repeated
inhalation
© Fotos: Bundesamt für Gesundheit (BAG), Schweiz
Hutzler C et al, Chemical hazards present in liquids and vapors of electronic cigarettes,
Arch Toxicol, published online 11 june 2014

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• Formaldehyde
• Acetaldehyde
• Acroleine
• Metals (nickel, chromium, lead)
• Appear to be produced during heating
Refs.:
Trehy ML, et al., J Liquid Chrom Rel Tech, 2011. 34(14):1442-1458; Laugesen M Safety Report on the Ruyan® e-cigarette Cartridge and Inhaled Aerosol. 2008;
Goniewicz ML, et al., Tob Control, 2013, in press ; Uchiyama S et al., J. Chromatography A, 2010. 1217(26):4383-4388; Sobczak A et al., Poster presented at
the SRNT conference. 2013; Goniewicz ML et al., Poster presented at the SRNT conference. 2013.Williams M et al., PLoS One, 2013. 8(3):e57987; IARC.
Agents Classified by the IARC Monographs, Volumes 1-107. 2013 last update: 10 April 2013;; DFG, MAK- und BAT-Werte-Liste 2008; Hutzler et al., 2014 Arch
Toxikol published online
Carcinogenic substances in vapour

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Nicotine
• Toxic
• Harms the unborn
• Tumor promoting
• Possibly carcinogenic
• Addictive
Grando SA , Connections of nicotine to cancer Nat Recv Cancer 2014, published online 15 May 2014
Counotte DS et al, The yin and yang of nicotine: harmful during development, beneficial in adult patient populations FrontPharmacol 2012 (3): 180. doi: 10.3389/fphar.2012.00180
Benowitz NL, Clinical pharmacology of nicotine Clin Pharmacol Ther 2008 (83/4):531-541

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Emissions
• Nicotine
• Particles (PM2,5)
• Flavours
• Carcinogens
• Much less than in secondhand cigarette smoke
• Nevertheless impairs the air (carcinogens! particles!)
© Fotos: Bundesamt für Gesundheit (BAG), Schweiz
Schober W et al, Use of e-cigarettes impairs indoor air quality and increases FeNO levels of e-cigarette consumers, Int J Hyg Environ Health 2014, Feb 27;
Schripp T et al. Does e-cigarette consumption cause passive vaping Indoor Air 2013; 23: 25–31;
Hutzler C et al, Chemical hazards present in liquids and vapors of electronic cigarettes Arch Toxicol, pubished online 11 june 2014

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Intoxication
• Increasing reports on intoxication of children
• Symptoms are mild and transient – so far
• Risk of overdosing (too many puffs, too deep inhalation)
Cantrell FL, Adverse effects of e-cigarette exposures J Community Health: published online 15 Dec 2013;
Ordonez J et al., Electronic cigarette exposures reported to poison centers, Meeting Abstract 242. Clin Toxicol 51:685–685;
Hua M et al., Health-Related Effects Reported by Electronic Cigarette Users in Online Forums, J Med Internet Res (2013)15:e59

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Directive 40/2014/EU Directive 40/2014/EUNot included Not included Not included Not included
Regulation by and beyond
directive 2014/40/EU

18.07.2014|
Regulation by directive 40/2014/EU
Proposal
leaflet + package!
• Helvetica, black, 9 Point
• Hazard symbols
Directive 2014/40/EU, article 20 electronic cigarettes
(4) Member States shall ensure that
a) unit packets of electronic cigarettes and refill containers include a leaflet with
information on:

18.07.2014|
www.easysmokers.ch
3 g) electronic cigarettes and refill containers are child- and tamper-proof, are
protected against breakage and leakage and have a mechanism that ensures
refilling without leakage
Proposal
Only pre-filled containers that can‘t be opened
(such as ink cartridges)

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Proposal
A precise list of banned additives
(according to art.7(6))
• Vitamins/ additives implicating health benefits:
fruit flavours
• Flavours associated with energy and vitality:
green tea, coffee, energy, etc.
• Additives that facilitate inhalation or nicotine uptake:
Menthol.
It can be assumed that the physiological effects of menthol
are the same for e-cigarette use as for tobacco cigarettes.
www.germanflavours.de
3 c) the nicotine-containing liquid does not contain additives listed in Article 7(6)

18.07.2014|
Regulation beyond
Objective
Protection against health hazards of inhalation of the
chemical mixture of electronic inhalation products
Proposal
Sales ban to minors (<18 years)
Protection of youth

18.07.2014|
Proposal
• Standardised packaging
• Standardised product design
• Ban of flavours that are attractive
to youth
Objective
Protection against new lifestyle products
that may facilitate initiation to nicotine and
tobacco products
http://www.supersmokerbluetooth.de
Protection of youth
Regulation beyond
www.happy-liquid.com, www.flavourart.nl

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Proposal
• Ban of e-cigarette use in non-smoking areas
Objective
• Protection against indoor air pollution
• Prevention of the renormalisation of smoking
Regulation beyond
Protection against emissions

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Objective
• No hazardous waste
• Promotion of recycling
Proposal
• Obligation to repurchase
• Special tax for the environment (?)
Regulation beyond
Protection of the evironment

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