E-cigarettes have caused a lot of controversy in the respiratory world since their increased prevalence within the last decade. Are they safe? Can they help patients quit smoking traditional cigarettes? Or will they rope kids into an early smoking habit? Research is still lacking to answer these clinically relevant questions, and yet the tobacco industry continues to churn out new and improved products. According to the American Heart Association (AHA), interested buyers can now find 466 brands and 7,764 unique flavors of e-cigarettes (Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: A policy statement from the American Heart Association. Available at: http://circ.ahajournals.org/content/early/2014/08/22/CIR.0000000000000107).
Concerned by the rising popularity of this unregulated tobacco product, the AHA decided it was time to make a stand. In August, it released “Electronic Cigarettes: A Policy Statement from the American Heart Association,” ultimately recommending e-cigarettes be subject to all laws that apply to other tobacco products.
“With the advent of e-cigarettes there has been a sea of change in the tobacco landscape,” said Aruni Bhatnagar, PhD, FAHA, lead author of the AHA’s Policy Statement on E-cigarettes, and professor of Medicine at University of Louisville, Louisville, Ky. “Hence, the American Heart Association wanted to develop a unified policy that regulates e-cigarette use, their health and safety, their efficacy as cessation aids, and second hand exposure to e-cigarette aerosol.
“Because of our concern for the cardiovascular health of our nation, we believe it is imperative that we develop evidence-based policy to minimize the untoward effects of e-cigarettes on cardiovascular health,” he continued.
Recommendations
The AHA’s policy statement recommends e-cigarettes be regulated by the FDA, which will ensure that there is quality regulation and disclosure of ingredients, as well as appropriate advertising, labeling, packaging, sales and distribution, said Bhatnagar.
And for good reason. Research has yet to show if long-term exposure to secondhand e-cigarette vapor is safe, and many clinicians are concerned that non-smokers will be involuntarily exposed to nicotine if they are sharing a confined space with e-cigarette users, according to Bhatnagar. Additionally, Bhatnagar emphasized the fear that allowing e-cigarette use in places where smoking is prohibited could seriously hamper efforts to enforce current smoke-free laws.
“Unregulated e-cigarettes could potentially turn back the clock to the days when smoking in public was normal behavior, undoing years of work on smoke-free laws,” he claimed.
The AHA’s policy statement includes 8 overarching recommendations to address these concerns:
- Include e-cigarettes in smoke-free air laws.
- Prohibit the sale of e-cigarettes to minors.
- Restrict the marketing and advertising of e-cigarettes to minors.
- Tax e-cigarettes at a rate high enough to discourage youth use, while retaining or increasing differentials with combustible products by increasing taxes on combustibles.
- Impose FDA regulation on e-cigarettes that addresses marketing, youth access, labeling, quality control, free sampling, and standards for contaminants. Companies should not be able to claim that e-cigarettes are a cessation aid unless they are approved by the FDA for that purpose.
- Include e-cigarette use in tobacco screening questions incorporated into clinical visits and worksite/community health screenings.
- Improve and increase surveillance on e-cigarette use and establish a research agenda.
- Include e-cigarettes in the definition of tobacco products (or tobacco-derived products) and smoking, not by creating a separate definition for e-cigarettes.
Youth
While the AHA knows e-cigarettes should be regulated as a tobacco product, gathering the evidence to support the policy was no small feat. User surveys are scattered across the globe, focusing on varying populations and based on differing criteria. But Bhatnagar and colleagues condensed the evidence and realized, “non-Hispanic whites, current smokers, young adults, and those with a higher education and higher income perceive e-cigarettes as less harmful … and are more likely to use them.” What’s more, one survey found that any use of e-cigarettes by students in grades 6 through 12 increased from 3.3% to 6.8%, just between 2011 and 2012.1
“There is robust marketing and advertising of e-cigarettes on television and in magazines using celebrities as well as flavorings to make these products particularly attractive to children and adolescents,” Bhatnagar explained. “Youth exposure to e-cigarette advertising increased over 250% from 2011 to 2013, with e-cigarette advertisements reaching over 24 million youth during this period.
“We hope that our policy will help in limiting e-cigarette access to youth, as we are deeply concerned that the increase in e-cigarette use could recruit a whole new generation of tobacco users,” he added. “E-cigarettes could be a route to nicotine addiction and a potential gateway drug in youth and non-smokers.”
Smoking Cessation
Beyond the concern for e-cigarette use among youth, Bhatnagar is alarmed by the continued push for e-cigarettes as cessation aids.
“There is not enough research to show that e-cigarettes are effective cessation devices, and the FDA has not approved them for this purpose,” he said. “Therefore, the American Heart Association does not recommend them as a primary cessation aid.”
Bhatnagar and his fellow authors only had two randomized controlled trials, a large cross-sectional study, anecdotal reports, and internet-based surveys for evidence of e-cigarettes as cessation aids. Even this small pool of information showed varying degrees of efficacy, none of which is conclusive. Until research sheds more light on the subject, the AHA wants to make sure e-cigarette companies can’t use smoking cessation as a selling point for their product.
Clinical Guidance
So what do all of these recommendations mean for you as a clinician? Some patients, and perhaps colleagues, will still argue e-cigarettes are safe and a good cessation tool. But with these recommendations in hand, you can be prepared to share what little evidence is out there — as well as your concerns.
“Clinical and healthcare providers should ask patients about e-cigarette use as part of their health exam,” Bhatnagar explained. “To the extent possible, clinicians should recommend approved cessation strategies that have been proven to be effective.”
But if your patient has tried all other cessation methods, e-cigarettes might be an alternative, and you shouldn’t discourage them from trying, according to the AHA guidelines.
“But clinicians should counsel their patients that the long-term impact of using e-cigarettes is not yet known, that they are not yet regulated by the FDA and that patients should set a quit date for their e-cigarette use,” Bhatnagar emphasized.
Two Steps Forward, One Step Back
E-cigarettes will most likely remain in the gray area between pariah and clinical tool for some time. The AHA’s overall message encourages clinicians to tread carefully with the product, and advocates for stronger regulation until more is known. Ultimately, the policy statement hopes to keep anti-smoking efforts moving forward, not backward.
“The association, along with other agencies, has worked diligently to de-normalize smoking, and as a result, smoking in most places is not an acceptable social behavior” Bhatnagar concluded. “Unrestricted access to e-cigarettes would erode these gains and make smoking or “vaping” an acceptable behavior once again, which would not only fuel nicotine addiction in our society, but could increase the use of conventional cigarettes as well.”
And no one wants that.
Rebecca Hepp is on staff at ADVANCE. Contact: [email protected].
