Norwegian Institute of Public Health responded to my commentary. Now they need to retract or revise their original statements

By Dr Farsalinos

You probably remember my comment on the Norwegian Institute of Public Health (NIPH) report on e-cigarettes and health risks. Dr Per Schwarze, Department director for Air Pollution and Noise, Norwegian Institute of Public Health published a response in the institute website. I would like to thank him for his polite response. Dr Schwarze gives me the opportunity to clarify and repeat my arguments, and to repeat my call to retract false statements mentioned in the report.

First of all, I should clarify that my previous comment did NOT ask for retraction of the whole report. The title of the comment is: “Norwegian Institute of Public Health must IMMEDIATELY retract false statements about passive e-cigarette exposure” (emphasis added by me). I was referring to statements about passive e-cigarette exposure, specifically to statements about high level of nicotine exposure and related risks.

Dr Schwarze cites studies (by Flouris et al. and by Ballbe et al.) finding similar levels of nicotine in the environment after e-cigarette use compared to tobacco cigarette use (second hand smoking or vaping), and similar levels of cotinine levels in people exposed to passive smoking and passive vaping. The study by Flouris et al. was not a second-hand exposure study because both cigarette smoke and e-cigarette vapor were introduced into the chamber by using air pumps. No human was smoking or vaping. But this is not the key issue. The important thing as mentioned in my previous comment was: “… passive exposure to e-cigarettes does not cause “similarly high nicotine levels” in the blood as that of passive smoking, but maybe similarly minimal levels of nicotine in blood” (emphasis added by me). I explained that cotinine levels (which are a measure of nicotine intake from either active or passive use) are >1000 times lower in passive e-cigarette exposure compared to active smoking (citing the same study by Ballbe et al. that Dr Schwarze has cited). I presented my calculations that such levels are not expected to cause any biological activity (the total nicotine intake over the whole day for a passive vapers is lower than the acute intravenous dose needed to cause a slight elevation in heart rate).

Dr Schwarze mentions in his response that: “However, we stand by our conclusion that a health risk cannot be ruled out”. I would accept that, but this is not the statement made in the original NIPH report. The report mentions: “one can expect similar harmful nicotine-related effects of passive smoking from e-cigarettes as for regular cigarettes”. This statement is not true for a simple reason: there has never been documented that second-hand exposure to nicotine from smoking (or from e-cigarette use) has any adverse effect on humans. There has never been a single documented case of addiction coming from second-hand exposure to nicotine (which makes sense since the levels of exposure are minimal). All adverse effects associated with environmental tobacco smoke exposure are caused by exposure to combustion products and combustion particles, not to nicotine. Nicotine does have acute cardiovascular effects, mainly elevation in heart rate and blood pressure. However, these are temporary and self-resolving. They are NOT indicative of any long-term effects. Acute effects are different from chronic effects; for example, there is a lot of evidence that smoking cessation ELEVATES the risk of future development of hypertension (which has been partly, but not totally and convincingly, attributed to weight gain). So, the acute effects of nicotine on cardiac hemodynamics should not be confused with long term effects, and the long-term effects of smoking on the cardiovascular system (stroke, myocardial infaction etc) should not be attributed to nicotine (let alone second-hand exposure to nicotine).

I agree with Dr Scwarze that a health risk cannot be ruled out, but this is not the statement they made related to second-hand e-cigarette exposure. Moreover, this is a convenient statement in medicine and can apply to anything, because risk is or could potentially be everywhere, and risk may even be present but not measurable (if extremely small). Any risk associated with second-hand vaping is more likely to come from propylene glycol or glycerol exposure (although I find this very unlikely), than from the levels of nicotine in the environment. My objection, and call for retraction, was related to the “high levels of nicotine intake by passive exposure” (which in reality are absolutely minimal), and to the adverse health effects of this (which do not exist) and the contribution to addiction (which also does not exist). I therefore call the NIPH to retract these statements (of course, I never mentioned that they should retract the whole report). 



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