With the FDA’s regulations awaiting finalization after the comment period, the American Heart Association (AHA) has released a policy statement on e-cigarettes. Coronary heart disease is one of the biggest smoking-related killers, so given that e-cigarettes have the potential to drastically reduce the numbers of these deaths, it would be reasonable to assume that the AHA would be wholly in favor of the technology. But this isn’t how things tend to work out.
In the FDA’s regulations, they hid behind a willful scientific ignorance as they proposed rules that will likely crush the whole industry (unless you have Big Tobacco’s financial backing). In the new statement published in the journal Circulation, the AHA comes out in support of the FDA’s proposal, and even advocates further actions such as including vaping in smoke-free air laws and increasing taxes, but manages to hold this view despite conducting a fairly reasonable analysis of the evidence beforehand. It seems like doublethink, but the AHA admits that e-cigarettes are likely much safer than smoking while still suggesting that strict regulation is necessary.
Summary
- The AHA is concerned about youth e-cig use, despite freely admitting that research consistently shows very little or no regular use among non-smoking youth, and no evidence for the “gateway” effect.
- They acknowledge clinical trials showing that ineffective, first-generation e-cigs produce quit-rates similar to nicotine patches and much more of a reduction in the number of cigarettes per day.
- The AHA accepts that chemical and toxicological evidence supports the notion that e-cigarettes are much safer than tobacco cigarettes.
- They accept the decreased second-hand exposure to toxic components from e-cigs, but are concerned about involuntary nicotine exposure in bystanders, despite research showing 10 times more nicotine present after a cigarette is smoked.
- The AHA supports the FDA’s regulation of e-cigarettes as tobacco products, and also advises adjusting smoke-free laws to contain them, as well as putting extensive restrictions on advertising.
- They support taxation on e-cigarettes to prevent youth access, but also want to put up tobacco taxes to maintain a difference in price in favor of e-cigs.
- According to their recommendations, clinicians should support those using e-cigs to quit if other methods have failed, but the AHA say there isn’t enough evidence to advise it as a primary strategy.
- The AHA says doctors should advise interested patients that e-cigs are unregulated, there isn’t sufficient evidence to say they’re effective and they contain low levels of toxic chemicals.
- Overall, given the overwhelmingly positive evidence provided, the AHA’s recommendations seem to reflect a desire to mindlessly repeat party lines rather than a genuine strategy for minimizing harm to the public.
The Evidence on E-Cigarettes
Overall, the AHA does a reasonable job of going over the evidence on e-cigarettes. I say reasonable, but there are some pearls of rank stupidity hiding in the full text. After an introduction to the technology covering the three generations of e-cigarettes (with some comical moments – such as mistaking PV as standing for “personal vapors” and a fumbling attempt at explaining advanced atomizers), they look at user characteristics and demographics before moving onto the evidence on e-cigarettes.
The first issue they address is the youth vaping, “protect-the-children” stuff. This is one of the only areas outside of the policy recommendations where they clearly let their personal viewpoints get in the way of a fair analysis of the available evidence (as is shown by their recent, credulous response to the new CDC-FDA study on youth e-cig use). After re-stating the fears of idiotic concerned public health advocates about e-cigs serving as a gateway to (or back to) conventional cigarettes, they discuss evidence from the National Youth Tobacco Survey from 2011 to 2012, as covered by the despicable liar paragon of scientific virtue that is Stanton Glantz.
They go over some of the scarier numbers from the research (pointing out that 1.78 million high school and middle school students had tried vaping in 2012, for example), but also hit on the crucial point that just 0.7 percent of never-smokers had used an e-cigarette in the past 30 days in the study, and admit that the research was incapable of determining whether they were used as a gateway to smoking. To bolster their obviously flawed viewpoint that e-cigarettes are attracting kids at an alarming rate, they then go on to make speculative statements about how marketing using celebrity endorsement and appealing flavors are employed “to make e-cigarettes especially more attractive and appealing to children and adolescents.”
For the evidence of their effectiveness for quitting, the AHA cites a large survey showing that in real-world situations (without additional support) e-cigarette users are more likely to quit than NRT users or those going cold turkey. They cite a study that compared past e-cigarette users (recruited through a smoking quit-line, meaning that these users had obviously already failed to quit by vaping) to non-users, and found that this group of e-cig users were less likely to be tobacco abstinent, but then discuss the e-cigs vs. patches clinical trial. This found six-month quit rates of 7.3 percent for the nicotine e-cig group, 5.8 percent for patch users and 4.1 percent with no-nicotine e-cigs. They point out, however, that e-cig users were more likely to still be smoking (with around a third of the sample transitioning to dual use) at six months than patch users (of whom just 7 percent were dual users). They pitch this as something negative, but in reality 57 percent of those in the nicotine e-cig group reduced their cigarette consumption by at least half compared to just 41 percent of the patches group.
For the overall safety of e-cigarettes, they point the reader towards existing systematic reviews (which includes Konstantinos Farsalinos and Riccardo Polosa’s review, but also suggests two from Glantz), but then provide a basic overview. They point out that there are trace levels of metals and other contaminants present in e-cig vapor, but acknowledge that tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons and volatile organic compounds have only been found at levels too low to cause risk to humans. They do mention the diethylene glycol found in one cartridge by the FDA in 2009, but the general message is still quite positive.
After pointing out that animal and laboratory evidence suggests that nicotine may promote the development and spread of cancer, they use evidence from both NRT and snus use in humans to show that e-cigs can be expected to be very safe in comparison to smoking. They conclude “although the adverse health effects of e-cigarettes are not known, they are likely to be much less than those of cigarette smoking, but could be significant in individuals with heart disease.” Although they spend too much time talking about a test conducted on flavor extracts, their summary of the toxicological research comes to a similar conclusion, that the available data suggests e-cigarette vapor is “much less toxic” than cigarette smoke.
They lose their relative rationality when it comes to e-liquid poisonings, though, commenting that “The concentrations of nicotine in e-cigarette liquids are high enough to be fatal to a child if even a few milliliters is ingested.” This is undoubtedly based on traditional but incorrect toxic dose for nicotine, and either reflects a clear lack of research or an outright refusal to admit that this assertion is completely baseless. They repeat the e-liquid poisoning findings reported by the CDC, pointing out that many cases involved children despite the fact that cigarettes poisoned many times more children over the study period.
Second-hand exposure to e-cig vapor is one of the major regulatory concerns, and one of the key points addressed in the policy recommendations section, but the evidence analyzed in the paper shows little cause for concern. The researchers acknowledge that most second-hand smoke exposure comes from “sidestream” smoke (from the burning tips of cigarettes), which doesn’t exist for e-cigarettes, and that chemicals found in passive vaping studies have only been detected in 5 to 40 times lower quantities than after cigarette smoking. A major concern for the AHA is passive exposure to nicotine, but they cite research showing that cigarette smoking causes 10 times higher ambient nicotine levels than vaping. They say that the biological effects of this exposure will undoubtedly be much less than those from smoking, but still stress that non-users will be exposed to some nicotine.
While there are some very questionable points in their analysis, the AHA didn’t really do too badly at summarizing the available evidence. They clearly share in the popular mistrust of e-cigs, but not enough to deny the basic point that e-cigs are undoubtedly many times safer than cigarettes. With that in mind, the best course of action (if your goal is to reduce the numbers of smoking-related deaths and illnesses) is obviously to promote vaping any way you can. But not according to the AHA…
E-Cigarette Policy Guidance from the AHA
The AHA supports the definition of e-cigarettes as tobacco products (despite their complete lack of tobacco), and even helped to write the definition of tobacco products so it would include them. After clearly reading the available evidence and interpreting it quite fairly, the tone then devolves into unsupported comments about re-normalizing smoking, eroding gains in smoking cessation, undermining indoor smoking bans and being a gateway to or back to cigarette smoking. You almost get the impression that this section was written before the summary of the research and then spurious justifications were added in later as needed.
The AHA supports the inclusion of e-cigarettes in smoke-free laws, despite acknowledging that there isn’t any evidence to support the notion that vaping has a damaging effect on bystanders. They say that the presence of nicotine is the reason for their support, but in their own analysis they acknowledge the vastly lower levels from vaping in comparison to smoking, not to mention the comparative ineffectiveness of e-cigarettes at increasing blood nicotine levels. Even in the AHA’s nightmare scenario of involuntary exposure to heavy e-cigarette use in a confined space, it’s hard to imagine that there would even be noticeable effects. Have you ever been in a room with smokers and felt a light-headed rush from the second-hand nicotine? Neither have I, and smoking leads to 10 times higher levels of nicotine than vaping. Of course it must be possible, it just seems extraordinarily unlikely from e-cigarette exposure. They also say that e-cigarettes could recreate the social norm around indoor tobacco product use, in willful ignorance of the fact that the true concern with regards to social norms is around combusted tobacco product use.
As would be expected from their sheer inability to appreciate that e-cigarette use in children (and adults) is confined almost entirely to smokers, they support both age restrictions and rules preventing the advertising of e-cigarettes to children, which they seem to think is purposeful. Prohibiting youth usage is also the stated reason they support increased taxation on e-cigarettes, because the increased cost would make it too expensive for youths to buy them. They recognize that cigarettes should be more expensive, though, so they also support an increase in tax on them too. Obviously, the reasonable step of putting in age restrictions should accomplish that in most cases, so there’s no reason to create barriers to adult use as well.
The AHA is generally in favor of the FDA regulations, although appears to be under the mistaken belief that there are provisions in the draft to ensure quality control in manufacturing, which the draft regulations are conspicuously missing. In addition to the FDA’s plans, quality control and the marketing restrictions they suggested, they also propose lowering the nicotine content of cigarettes, with the aim of making them less addictive and comparatively increasing the appeal of e-cigarettes. They also support the tobacco product definition in state law, primarily because they feel it may jeopardize smoke-free legislation otherwise, but still say they should be treated differently from cigarettes in taxation and regulation.
For clinicians, they advise a cautious support of efforts to quit smoking through vaping, but mainly in cases where traditional methods have proven ineffective or are inappropriate. They say there isn’t enough evidence to support the use of e-cigarettes as a primary method for cessation (although they’re apparently satisfied with patches and gums, which they freely admit are less popular and provide evidence that they’re slightly less effective than e-cigs). They say clinicians should inform patients that although e-cigs are much less toxic than cigarettes, they’re unregulated, contain low levels of toxic chemicals and have not been proven effective as cessation devices. This is clearly not a wholehearted recommendation; if anything it sounds like they think smokers trying to quit through vaping should be discouraged.
Finally, the AHA says more evidence is needed on e-cigs, and that their recommendations could change based on future findings. They also point out that research will need to try to keep pace with the rapid evolution of the technology: for example, the patches vs. e-cigs clinical trial used a cig-a-like model which is now pretty much obsolete. They advise more chemical studies (in particular on how different usage patterns affect the chemistry of vapor), more on perceptions about vaping, usage habits, their health effects and toxicity, studies on second-hand and third-hand (I wish this was just a joke, but they’re serious) exposure, how effective they are for quitting, research on marketing techniques and papers evaluating the effects of taxation. In short, they say we need to know more about everything.
Conclusion
The AHA’s policy statement reads a lot like they’re struggling with cognitive dissonance – the tension from holding two conflicting ideas in your head simultaneously. On one hand, they don’t want to sound like bumbling idiots when it comes to the science, so are willing to point out that e-cigarettes are vastly safer than tobacco cigarettes, but on the other hand their inherent opposition to anything similar to smoking drives them to suggest restrictive rules anyway. The real question is, if e-cigarettes are hardly used by young people, are much safer than smoking (to the point where it’s unclear whether they’d have any damaging effects at all), and are as effective as existing methods for quitting smoking (or likely more so), doesn’t any action that limits their availability or appeal risk putting off would-be switchers and thereby allowing them to continue smoking?
The AHA might want to have it both ways –sticking by the science (reasonably well, at least) and repeating the party lines when it comes to regulation – but it really doesn’t work that way. The party lines are just bunk; nonsense that persists in the face of contradictory evidence and should be valiantly ignored. We don’t have the specific long term evidence yet, no, but we do know enough to make a pretty strong prediction: e-cigarettes are undeniably much safer than cigarettes, in the long or short term. That, in itself, should be enough to support them wholeheartedly.