American Heart Association raises concerns about e-cigarettes

The American Heart Association (AHA) has come out with a policy statement on the use of e-cigarettes (ecigs), making a case for tighter control of e-cigarette sales and use.

The policy statement was published online in the AHA’s journal, Circulation.

The article cites studies, information from the Food and Drug Administration (FDA), the Centers for Disease Control (CDC), the World Health Organization (WHO) and other health organizations. The article also refers to statements made by the American Lung Association (ALA), American Thoracic Society (ATS) and the Forum of International Respiratory Societies (FIRS.)

Among the points raised was one I’d raised previously — namely, that the content of ecig cartridges is largely unknow.

E-cigarette via Shutterstock

E-cigarette via Shutterstock

Cartridges contain nicotine in varying amounts, and there are no current satisfactory labeling requirements for ecig cartridges. Many contain glycerol, propylene glycol, flavoring compounds, stabilizers and other additives. The FDA’s Center for Tobacco Products says that it can’t say definitively what is in the solution in the cartridge, or in the inhaled vapor. Some chemicals, when heated during smoking an ecig (vaping), can undergo a chemical conversion to one, or more, different compounds that may have different effects from the parent compound. Glycerol and propylene glycol, for example, when heated, can undergo chemical changes to formaldehyde and acetaldehyde which are carcinogens.

In addition to nicotine, carcinogens may be produced. The New York Times has an article and video on the subject. Depending on exactly what else may be contained in the cartridge, other harmful substances may be released, as well. The FDA, and other organizations, want to require the manufacturers of ecig cartridges to provide a list of exactly what compounds are present in the cartridges that they market.

More from the article in the journal Circulation:

Although the levels of toxic constituents in e-cigarette aerosol are much lower than those in cigarette smoke, there is still some level of passive exposure to organic compounds, nicotine, and fine particles.

To date, there is insufficient evidence to support the notion that exposure to exhaled aerosol has a deleterious impact on bystanders.

Some studies have found very low concentrations of air pollutants across different types, liquids, puff durations, and nicotine concentrations.

The levels of particle and nicotine exposure vary with the composItion of the liquids, the type of e-cigarette, size of the room, puff duration, interval between puffs, and the number of users. Nevertheless, there is concern that nonsmokers will be involuntarily exposed to nicotine, which could be substantial where there is heavy e-cigarette use in confined spaces.

Moreover, unregulated e-cigarette use has the potential to recreate a social norm around tobacco product use in public places, unraveling decades of work on comprehensive smoke-free air laws. (emphasis mine)

In addition, it may promote the image that vaping is accepted and popular. One study, done in teens, showed that many had positive impressions of vaping, saying that it was “cool” and “high tech.” Some said that they felt like rulebreakers when they used (or watched others use) ecigs. They could vape where others couldn’t smoke and could get around “no smoking” restrictions.

Children, teens and young adults constitute a growing population of ecig users. Ecigs all contain nicotine which is known to be addictive. By 2012, over 1.7 million high school students were estimated to have used ecigs. This is a 50% increase over date from previous years.

Public health experts are concerned that using ecigs will lead to the teens to using regular cigarettes as well. One study showed that some teens went on to become regular cigarette smokers; some used both products: ecigs and regular cigarettes.

The CDC reported in April of this year, that there have been increasing numbers of cases of children who have been exposed to the liquid nicotine formulation used in e-cigarettes. The CDC cites calls to poison control centers. Many of the calls involve young children who have been exposed to the liquid. It is toxic and can poison the children if they inhale it or drink it. It is also toxic if absorbed through the skin, so some children have been exposed by damaging cartridges and then playing with them.

The WHO has said that smoking ecigs poses risks not only to pregnant women, but to their developing fetuses as well. Research has shown that nicotine (and its metabolites) cross the placenta. One of their effects can be to decrease blood flow to the placenta and, thus, to the fetus. The nicotine can actually be concentrated so that the fetus is exposed to a higher concentration of nicotine than the mother. The effects are dose-dependent. The more nicotine that the mother inhales, the more deleterious it is to the fetus.

Ecigs have been touted as a means to quit smoking by substituting one form of nicotine (supposedly “safer”) than other forms (inhaled tobacco smoke, smokeless tobacco, etc.) Yet, some research shows that some smokers use ecigs simply as a bridge until they can smoke their next cigarette. They are not trying to quit, merely getting one or more doses of nicotine when they can’t smoke tobacco.

FIRS (an international group of professionals who are specialists in lung diseases) says in a position paper:

• The safety of electronic cigarettes has not been adequately demonstrated.

• The addictive power of nicotine and its untoward effects should not be underestimated.

• The potential benefits of electronic nicotine delivery devices, including harm reduction and as an aid to smoking cessation, have not been well studied.

• Potential benefits to an individual smoker should be weighed against harm to the population of increased social acceptability of smoking and use of nicotine.

• Health and safety claims regarding electronic nicotine delivery devices should be subject to evidentiary review.

• Adverse health effects for third parties exposed to the emissions of electronic cigarettes cannot be excluded.

• Electronic nicotine delivery devices should be restricted or banned, at least until more information about their safety is available.

• If electronic nicotine delivery devices are permitted, they should be regulated as medicines and subject to the same evidentiary review of other medicines.

• If electronic nicotine delivery devices are not regulated as medicines, they should be regulated as tobacco products.

• Research, supported by sources other than the tobacco or electronic cigarette industry, should be carried out to determine the impact of electronic nicotine delivery devices on health in a wide variety of settings.

• The use and population effects of electronic nicotine delivery devices should be monitored.

• All information derived from this research should be conveyed to the public in a clear manner. (emphasis mine.)

So, ecigs contain nicotine which is addictive. They can produce carcinogens, particulates and, possibly, other compounds that are dangerous. Nicotine from ecig cartridges can be toxic and even fatal to children. Nicotine can cause fetal damage and death when pregnant women use them, much like regular cigarettes. Ecigs can be attractive to children and teens from a psychological standpoint. Their ability to help people to stop smoking has not been well demonstrated.

What the FDA aims to do is to require that the makers of ecigs:

  • Register with the FDA
  • Provide a list of ingredients
  • Seek FDA approval to market their products
  • Seek approval to make direct and implied claims of reduced risk
  • Include health warnings

These do not seem to be excessively restrictive requirements. Even to the degree that two ecig manufacturers are supporting what the FDA is planning to do.

Lorillard agrees with the FDA’s position and has said that it has already started to implement some of the proposals.

NJOY, another manufacturer, says that it wants to make tobacco smoking “obsolete.” NJOY feels that ecigs are better alternatives to tobacco and will reduce both heart disease and cancer in those who use ecigs vs. smokable tobacco products.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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