The American Heart Association issued new policy recommendations (link live at embargo) today on the use of e-cigarettes and their impact on tobacco-control efforts. The guidance was published in the association's journal, Circulation.
Based on the current evidence, the association's position is that e-cigarettes that contain nicotine are tobacco products and should be subject to all laws that apply to these products. The association also calls for strong new regulations to prevent access, sales and marketing of e-cigarettes to youth, and for more research into the product's health impact.
"Over the last 50 years, 20 million Americans died because of tobacco. We are fiercely committed to preventing the tobacco industry from addicting another generation of smokers," said Nancy Brown, CEO of the American Heart Association. "Recent studies raise concerns that e-cigarettes may be a gateway to traditional tobacco products for the nation's youth, and could renormalize smoking in our society. These disturbing developments have helped convince the association that e-cigarettes need to be strongly regulated, thoroughly researched and closely monitored."
"E-cigarettes have caused a major shift in the tobacco-control landscape," said Aruni Bhatnagar, Ph.D. FAHA, lead author and chair of cardiovascular medicine at the University of Louisville. "It's critical that we rigorously examine the long-term impact of this new technology on public health, cardiovascular disease and stroke, and pay careful attention to the effect of e-cigarettes on adolescents."
The policy statement recommends a federal ban on e-cigarettes for minors and details concerns that these products may be another entry point for nicotine addiction among young people. The authors cite one JAMA Pediatrics study of 40,000 middle and high school students that indicated adolescents consider e-cigarettes as high-tech, accessible and convenient, especially in places where smoking cigarettes is not allowed.
Echoing its recent comment letter on the Food and Drug Administration's proposed tobacco oversight rule, the association recommends strict laws that curb the intense marketing and advertising of e-cigarettes, and ban flavorings in these products.
Ads using celebrities and alluring flavors make the products more appealing to children and adolescents. A recent Pediatrics study cited youth exposure to e-cigarettes advertising skyrocketed over 250 percent from 2011 to 2013, effectively reaching 24 million young people.
"In the years since the FDA first announced it would assert its authority over e-cigarettes the market for these products has grown dramatically," Brown said. "We fear that any additional delay of these new regulations will have real, continuing public health consequences. Hence, we urge the agency to release the tobacco deeming rule by the end of this year."
In addition to federal oversight of e-cigarettes, the association guidance also examines state smoke-free laws in relation to these products. While the toxic substances in e-cigarettes are lower than those in cigarette smoke, non-smokers could be involuntarily exposed to nicotine in any confined space where e-cigarettes are used. 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 and hampering current enforcement. Given these concerns, the association supports including e-cigarettes in these state laws, if the change can be made without weakening existing laws.
Another key recommendation examines e-cigarettes in tobacco-cessation counseling. The statement points to the lack of evidence establishing e-cigarettes as a primary smoking-cessation aid. Some studies suggest that the use of e-cigarettes to help smokers quit may be equal or be slightly better than nicotine patches. The association will continue to encourage clinicians to use proven smoking-cessation strategies as the first line of treatment for any patient. But it reiterates in the statement that when repeated efforts with conventional treatment fails, is intolerant, or rejected by a patient who wants to utilize e-cigarettes to help them quit, clinicians should not discourage their use by the patient.
However, the statement stresses that clinicians be educated so they can inform patients that e-cigarettes are unregulated, may contain low levels of toxic chemicals, and have not been FDA-approved as cessation devices. The association also proposes that given the lack of long-term research studies on e-cigarette safety that it's appropriate for a health care professional to suggest that a patient set a quit date for their e-cigarette use.
Finally in the new statement, the association calls for comprehensive and continuous research on e-cigarettes' use, their characteristics, their marketing, and their long-term health effects on individual users, the environment, and public health.
"Nicotine is a dangerous and highly addictive chemical no matter what form it takes – conventional cigarettes or some other tobacco product," said association President Elliott Antman, M.D. "Every life that has been lost to tobacco addiction could have been prevented. We must protect future generations from any potential smokescreens in the tobacco product landscape that will cause us to lose precious ground in the fight to make our nation 100 percent tobacco-free."
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