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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  • CarolWJohnson

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  • http://hunteratrandom.blogspot.com/ rmthunter

    That was my thought, which made it seem even weirder that they would not cover the inhaler, even though they covered the patch (which was a big flop for me).

  • http://www.americablog.com/ Naja pallida

    Insurance companies just make it up as they go, and since there are no sensible rules otherwise, they can cover what they want, when they want, and for whatever amount they want… but since nicotine inhalers are marketed and prescribed as smoking cessation devices, it is in their best interest to cover whichever method you choose to use to try and quit. Covering a way to quit is theoretically cheaper than covering smoking-related health problems.

  • http://hunteratrandom.blogspot.com/ rmthunter

    It’s not the helping to quit smoking part, it’s the not knowing what’s in them part — sounds like it could just as bad as tobacco. I have a nicotine inhaler, which I hate — it’s not a good substitute — very hard draw, uses menthol as the carrier, and it really irritates my throat.

    (Funny thing about the expense: my insurance company, after covering two boxes of the inhaler and cartridges, sent me a letter saying “We don’t actually cover this, but we will this time.” I’m still trying to figure that out.)

  • JDH

    Not really. They are saying they haven’t studied whether it can help people quit smoking, which is different than concluding that it does not help. Hilariously, prescription nicotine inhalers have existed for years, and they are ludicrously expensive. So there is enough science on inhalers being helpful but they are fine with misleading people by repeating the “no studies” line instead of using basic logic to say that if inhalers are effective than vaping shows promise.

  • docsterx

    The World Health Organization came out with a statement yesterday on ecigs. It says, in part:

    “WHO urges e-cigarette ban on sales to minors

    Benefits and risks of e-cigarettes are a controversial issue. The
    World Health Organisation (WHO) now calls for a ban on sales to minors. A
    statement published by the American Heart Association in “Circulation”
    follows in the same vein: accordingly, e-cigarettes should be
    categorised like other tobacco products and subject to strong
    regulations.

    The aromatised vapour enriched with nicotine that is
    inhaled by an e-cigarette user poses a “serious risk” to foetuses and
    adolescents, the WHO says. They are “probably less harmful” than real
    cigarettes, but until it has been proven that they are not harmful to
    other individuals, e-cigarettes should be banned from public indoor
    spaces, the WHO writes in the statement.

    A similar position is
    supported by the American Heart Association, which recommends a federal
    sales ban for minors and the inclusion of e-cigarettes in already
    applicable laws that apply to tobacco products. The reasons are not only
    the, to date, unclear consequences for people’s health, but also the
    concern that the electronic cigarettes may be another entry point for
    nicotine addiction among adolescents. A lack of regulations may also
    have a negative effect on the success of the anti-smoke campaigns
    carried out over the last few years.

    Furthermore, the WHO points
    out that there are no studies confirming that e-cigarettes help smokers
    quit. The American Heart Association also proposes that physicians
    should refrain from recommending e-cigarettes as a primary
    smoking-cessation method. However, they should not discourage the use
    for patients that reject other methods or if these have turned out to be
    useless.”

    http://www.merckmedicus.com/medical-news/d40c38f561ef3bdeb9880b1962a2f034?WT.mc_id=MM_RET_MVD_US_en_35&e=[email protected]

  • luzeelu

    Maybe they ARE bad, but…

    After smoking cigarettes for more than 50 years, e-cigs have made it possible for me to quit. I’m well aware that tobacco/nicotine is a terrible addiction but it was the only way I could do it, having been around smokers and cigarettes my entire life. I ordered my first “kit” the end of January, gradually reducing the number of “real” cigarettes I smoked throughout February. I haven’t had a cigarette since March 1 and so far, so good. An added bonus is that I’m spending a LOT less money.

    Perhaps one of these days I’ll be able to quit these as well, but meanwhile, at least I’m not smoking tobacco and after all these years, I think that’s a good thing.

  • S1AMER

    The problem with letting people kill themselves with dangerous products and reckless behaviors is that the rest of us usually end up paying the medical bills.

  • http://hunteratrandom.blogspot.com/ rmthunter

    Thanks for the post. I was about to start researching e-cigarettes as a way to stop smoking tobacco, but it looks like a case of frying pan/fire, or close enough.

  • Indigo

    Yes and no. From what I’ve heard, vaping with cannabis content is also possible.

  • bkmn

    Yup, their most cited argument is that the vapor is just water vapor. A complete lie and they know it.

  • http://twitter.com/#!/dameocrat Dameocrat

    Keeping Marijuana illegal was a big cash cow for the Prison industry and the DEA. Corrupt politicians want to replace Maryjane with tobacco cigarettes. It is plain at the nose on your face when you consider all the stories where government agencies have openly stopped hiring smokers, and encourage other businesses to do the same. They want smokers imprisoned, or dead, like other drug addicts. If people quite smoking, in favor of ecigs, it would harm that effort. Not to mention forcing another group into the underground economy like others people addicted to illegal drugs. This takes them out of the job market, and kills many of them off. A big bonus in an economy that really doesn’t provide good jobs for many people. They don’t give a shit about public health, anymore than any other prohibitionists do.

  • nicho

    The tobacco industry’s business model is selling poison. It doesn’t matter how they package it.

  • http://www.rebeccamorn.com/mind BeccaM

    I could not agree more.

  • bkmn

    As a former smoker, anyone who trusts the money making interests of the e-Cig industry should take the time to pre-pay their funeral costs.

  • http://www.americablog.com/ Naja pallida

    e-Cig users may not have actual scientific data to educate themselves, but a simple look at the companies that are pushing e-Cigs, and defending them so desperately without any scientific evidence to back them up, should tell users everything they would ever need to know. Nobody should have any reason at all to trust anything that comes out of the tobacco industry. I can’t fathom how anyone could fall for their bullshit all over again, after they have spent billions of dollars defending their right to kill their customers.

  • http://www.rebeccamorn.com/mind BeccaM

    At the risk of using a bad word, I’m somewhat libertarian-minded when it comes to drug use. In general, if people want to poison themselves, knowing the risks, then who am I to interfere?

    But that’s the problem isn’t it? These devices — in several different forms — were rushed to market without anything like formal, neutral scientific and health testing. Many of the risks are unknown. It literally is not possible for an e-cig user to make a truly informed decision, because the information doesn’t exist.

    My other objection has to do with the other thing we’re seeing: People vaping their e-cigs in enclosed spaces, where others have no choice but to inhale the fumes. Exposing their kids to it. Like I said, if someone wants to take a risk with their own health, that’s one thing, but the problem with products like traditional cigarettes is one smoker in an elevator makes everybody a smoker for the duration. The right to choose to ingest a drug or any other substance should stop at other people’s space.

  • S1AMER

    At this point, people who smoke these things are fools. Utter fools.

    I’m troubled at how many people who actually quit real cigarettes some time in the past have resumed smoking with these things, thinking (hoping?) they’re harmless. Apparently kids, who might have stayed away from real cigarettes, are taking up smoking (and becoming addicted?) with e-cigs.

    It’s all so foolish, with our current limited knowledge of long-term consequences. And it’s also sad, given how many people had kicked the addiction or were avoiding becoming addicted in the first place. Sad, sad, sad.

    But I may have a solution: What if Obama came out tomorrow and said he thinks e-cigs are the best thing ever? Wouldn’t that get all the Republicans, and much of the press, working against e-cigs, or at least advocating major research?

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