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The Death Toll from First- or Second-Hand Tobacco Smoke

  • 16% of adults in North and South America
  • 20% of US citizens
  • 16% of Europeans
  • 25% of European men
  • 10% of Southeast Asians
  • 13% in the Western Pacific 

The WHO (World Health Organization) global tobacco death toll: 6 million people every year. Without a rapid reversal, the WHO predicts 8 million deaths per year by 2030. In the 20th century 100 million died of tobacco use, and the WHO expects that to surge to 1 billion in this century.  

Tobacco death is a recognized global epidemic. 

A Safer Alternative

When Hon Lik of China released the first modern e-cigarette to the Chinese market in 2003, it was his way of inching towards a cure for the tobacco-induced cancer that had killed his father.

E-cigarettes are considered a “harm reduction” strategy: they contain a fraction of the nicotine and almost none of the carcinogens in a normal cigarette. The harm-reduction effort gained credence when former U.S. Surgeon General Dr. Richard Camona, a smoking-ban figurehead, joined the board of one of the biggest e-cigarette companies, NJOY, Inc. 

Back in 2003, Dr. Camona had warned the US Congress to be wary of “safer” alternatives to tobacco. Later, his 2006 publication stated categorically that there was no safe amount of cigarette smoke. Now he is an e-cigarette advisor.

Apparently, it pays to take a closer look at e-cigarettes.

Vaping Vogue

Big-screen smoking glamor is back. Say goodbye to tobacco’s wrinkling ravages, yellow teeth, morning cough, sinus congestion, and the stale stench in hair and clothes; and say hello to an elegant, guilt-free nicotine fix.

Actress Katherine Heigl wanted to quit smoking for the sake of her newly adopted child. After every other method, including prescription drugs, failed her, she resorted to e-cigarettes. She now has no intention of kicking the vaping habit. Puffing away with blonde élan and a charming hint of self-deprecation in an interview with Parade, she said: “I know it's ridiculous, but it's helping me not to actually smoke real cigarettes. You feel like you are smoking, and you get to exhale, but it's just water vapor… I’m essentially humidifying the space.”

Funny, but not exactly true.

Vaping: A Deceptive Term

The term “vape” tricks consumers into imagining that they are merely inhaling and exhaling water vapor laced with nicotine. In fact, the “e-liquid” is comprised of nicotine concentrate, propylene glycol (and/or vegetable glycerin), and flavoring. It’s not water.

Anatomy of the E-Cigarette

Very simple: a cartridge delivers “e-liquid” into an atomizer, which heats it into a vapor. The vapor is inhaled.

What are the “e-liquid” Ingredients?

That’s a good question.

Most e-cigarettes are still manufactured in China, where they originated. Even those labeled “Made in the USA” are largely cobbled together from Chinese components. These imports are not yet standardized nor monitored, and the ingredient label is something of a hypothesis, rather than a pure statement of fact.

The FDA (Food and Drug Administration) issued a warning, citing preliminary tests which revealed e-cigarettes to contain as much as twice the nicotine approved, as well as a smattering of poisonous chemicals, like diethylene glycol (used in antifreeze), the carcinogen nitrosamine, and other known toxins. Clearly, these toxins are residual contaminants from the manufacturing process, predominately from low-grade chemical components.

The Roll-Your-Own Gang

While the FDA has deemed propylene glycol (PG) safe as a food additive, there is a growing practice amongst vapers of purchasing industrial-sized (up to 60 L) drums of PG, plus large quantities of nicotine concentrate, online, in order to mix their own “e-liquid”.

There is no way to verify where these ingredients have been sourced, or to rule out the presence of dangerous contaminants, even carcinogens.

How Bad Are Second-Hand Vapors?

As Ms. Heigl and others “humidify the space”, what are they actually contributing to the air quality of their neighbors, or their children?

The most recent study published in the Oxford School of Medicine’s Nicotine and Tobacco Journal echoes an earlier study published by the Frauenhofer Institute in Germany. Both cite the toxic fine-particle levels to be negligible in comparison to cigarettes, and note that the e-cigarette obviously does not release the combustion toxins of tobacco cigarettes.

Nicotine, however, remains an issue. According to Oxford, although the average e-cigarette produces one tenth of the second-hand nicotine of a tobacco cigarette, the effects of these levels on more susceptible groups, like children, pregnant women, and heart patients, requires further investigation.

Nicotine: The Agony and the Ecstasy

So far nicotine, removed from tobacco cigarettes, has not been proven to cause cancer. Still, we know that nicotine is the foremost addictive substance in cigarettes. Is the addiction itself harmless?

The Ecstasy

What the Mayo Clinic and other therapeutic centers call “nicotine dependence” is a cycle in which the brain requires regular doses of nicotine, with increasing frequency and magnitude, to maintain a normal standard of happiness.

Nicotine rushes to the brain within six to ten seconds after inhalation. There, nicotinic receptors process it (as a replacement for a natural body chemical) and release dopamine, which creates the sensation of stimulation and pleasure. Nicotinic receptors multiply to field the increased influx of nicotine, and the brain further adapts to the stimulant by gradually relying more on the nicotine to incite dopamine production, instead of producing dopamine in normal quantities on its own.

While this addiction cycle is established rapidly through regular nicotine intake, the altered brain patterns are slow to be corrected when a person tries to quit smoking. Studies show that sudden, complete nicotine withdrawal induces severe irritability and depression for approximately six weeks in regular smokers, and that the nicotine craving can endure for a full year or beyond.

The Agony

The fact that nicotine is also a poison—encoded in tobacco plants to drive away pests—is blithely overlooked in the vaping craze.

Nicotine in mothers can cause birth defects and developmental disorders in their children. The American Heart Association reports that nicotine contributes to blood vessel damage and heart disease.

25 studies of 1.2 million participants also revealed that regular smokers were 44% more likely to develop type-2 diabetes, resulting in blindness, heart disease, and amputation. The studies, like most smoking studies, did not isolate nicotine from the rest of the chemical constituents of cigarettes; but subsequent studies of nicotine gum and patch users have revealed a correlation between nicotine use and the insulin resistance leading to diabetes.

The conclusion: nicotine, all on its lonesome, is bad for you.

Still, if you quit smoking, you drop more than 60 known carcinogens in cigarettes, right?

Sure, If You Actually Quit

Every few months a new, “qualitative” (miniscule) study hits the news, reporting on a handful of smokers who probably stopped smoking through e-cigarette therapy.

In other words, smoking-cessation claims have yet to be proven. Some people, optimally, vape for a few months and then give up nicotine altogether. Other smokers supplement smoking with vaping, curbing, but not quitting, the cigarette habit. Often vaping just replaces smoking. Some people, teens especially, are introduced to the joys of nicotine for the first time through vaping, and then graduate to smoking.

Teens Getting Hookah-ed

If celebrities and cover-girls with e-cigarettes dangling off their glossy lips weren’t enough, what is the target segment for all those bright colors, cartoon pictures, and candy flavors: Adults?

The Mayo Clinic reports that most adult smokers start as teens, and that teens are biologically more susceptible to nicotine addiction at relatively low usage levels. As the addiction blooms, so does the craving for more powerful hits. So the question is: Do teens turn to e-cigarettes to battle pre-established smoking habits, or is the e-cigarette more like the witch’s house in Hansel and Gretel, a lip-smacking lure into the trap of nicotine addiction?

The CDC (Center for Disease Control) reports that 10-20% of teen e-cigarette users never smoked prior to vaping. While teen cigarette smoking is down slightly, teen e-cigarette usage nearly doubled in only one year, and 76% of teen vapers also smoke.

Taking their cue from Hollywood, many teens also equate vaping with water vapor, and they believe that if e-cigarettes are safer, so are hookahs (water pipes). Teen hookah usage rose last year from 4.1 to 5.4%. According to the WHO, hookah users inhale up to 100 cigarettes worth of tobacco in a friendly, hour-long session.

Now that tobacco companies are joining the e-cigarette fray, the chance is even greater that we are seeding a new generation of addicts.

Really Big Business

Since its inception in 2003, the vaping industry has exploded to USD 2 billion per annum. Wells Fargo expects sales to exceed USD 10 billion by 2017, and Bloomberg predicts e-cigarette sales will surpass cigarette sales by 2047. No wonder big tobacco is getting on board fast.

Accordingly, Bloomberg published an advisory report on four ways for companies to invest, before rules and regulations strangle the spectacular profit margins.

What Are the Rules So Far?

In case you were hoping to grab a nicotine fix in flight, most airlines now prohibit vaping, although no official legislation exists.

In the USA, the FDA has issued warnings about potential harm, but is postponing an official statement on the health effects, pending further research. Many regulators want to wait to find out if e-cigarettes prove to be a successful smoking-cessation remedy. Individual states have implemented a disparate variety of rules for displaying and selling e-cigarettes. One state prohibits sellers from displaying e-cigarettes alongside candy.

Some nations have made more progress. Ironically, the government in the Netherlands attempted a total ban, which didn’t pass. But several other countries have instituted total bans, mostly out of concern for children.

Marketing is prohibited altogether in several countries, as is the sale to minors.

Many countries have instituted a partial-permission system in which the e-cigarette devices may be sold with nicotine-free cartridges, but refill cartridges with nicotine are prohibited. Switzerland has banned use on public transport, and prohibits sale within its borders, but allows the import and use of e-cigarettes. France has extended its public smoking ban to include e-cigarettes.

The UK is alight with debate. In January of this year, legislators proposed an amendment to England’s Children and Families Bill, which would ban the sale of e-cigarettes to teens. On the other hand, several UK representatives object to EU regulations which would restrict both the sale and marketing of e-cigarettes, on the grounds that they are certainly a healthier alternative to smoking, as well as a profitable new industry.

In fact, an October 2013 EU proposal would have regulated e-cigarettes as medicinal products. It was rejected. In February 2014, the European Parliament voted on decisive legislation, which awaits only the ratification of member states in April. Based on the concern that e-cigarettes ultimately serve as a “gateway” to cigarettes and harder substances, the new laws focus on castrating the marketing aimed at teens. E-cigarette advertising will be treated like tobacco marketing, prohibited across the EU from mid-2016 onward. And like tobacco cigarettes, e-cigarettes will have to be childproofed and labelled with explicit health warnings. The new rules also address ingredient inconsistencies, prescribing a limit of 20 milligrams of nicotine per milliliter, roughly the amount in normal tobacco cigarettes. Other nations are now expected to adopt a similar stance.

How Should Insurers Respond?

What kinds of policies can insurers reasonably provide sellers or manufacturers amidst the uncertain health consequences, the ingredient guessing game, and inconsistent legislation across jurisdictions?

If tobacco exclusions do not apply, one solution could be a “claims-made” policy, which limits claim exposure to carefully defined time periods and triggers, and which excludes bodily injury or addiction as a consequence of nicotine consumption, which has long been established as harmful.

Hazy Future

Replacing cigarette and other tobacco use with e-cigarettes qualifies as “harm reduction”, or the lesser of two evils. But the long-term effects of vaping e-cigarettes, with ingredient wild cards and virtually no monitoring, have yet to be measured.

Class-action lawsuits are already underway, and the regulatory landscape isn’t going to simplify matters on either side anytime soon.

The future still looks hazy, for smokers, for vapers, and for the next generation.


Markus Kälin, PhD, is Senior Vice President and XL Group’s Head of Risk Engineering for International Casualty. Dr. Kälin offers expertise in biotechnology, pharmaceuticals, and medical equipment.

  • About The Author
  • Senior Vice President, Head of Casualty Risk Engineering, International Property and Casualty, AXA XL
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