Leadership Focus: The Importance of Curbing Smoking and Regulating E-Cigarettes

By Patrick T. O’Gara, MD

The American Heart Association (AHA) in August released a policy statement on electronic cigarettes (e-cigarettes). I commend the AHA for addressing this hot topic, and for shedding light on the importance of expanding regulative authority over the e-cigarette.

Nearly 50 years ago, low-tar cigarettes came on the market with the suggestion that they were safer than regular cigarettes. Smokers either switched brands instead of quitting, or even started smoking under the mistaken impression that low-tar cigarettes were a healthier choice. We learned years later that low-tar cigarettes were actually more likely to lead to lung cancer and no better for the heart. As the United States has made significant headway against smoking, the stakes are too high to make the same mistake with e-cigarettes, but we seem to be headed in that direction. Advocates of battery-operated e-cigarettes, battery-operated devices known as e-cigarettes, argue that inhaling the vapor of the electronic products is less dangerous than smoking. In addition, advocates suggest e-cigarettes are an effective aid to quit smoking.

Evidence about safety of e-cigarettes and their effectiveness for smoking cessation is ambiguous at best, however, and e-cigarettes may well be an entry point for new smokers and nicotine addiction. No well-controlled peer-reviewed studies support the claim that e-cigarettes are safe, that they have fewer long-term negative health effects than cigarettes, or that they are effective aids for smoking cessation. Meanwhile, e-cigarettes are gaining momentum with minimal regulation of their ingredients and marketing tactics. E-cigarettes are battery-operated devices that heat a liquid mix of chemicals, usually including nicotine, turning the liquid into a vapor that is inhaled.

E-cigarettes are marketed and sold where young adults gather; in most states they are available in shopping malls, convenience stores, and on the Internet. Celebrities tout their use and advocate for their sale. They come in hundreds of flavors like “grape soda” and “pineapple punch” that appeal to children and non-smokers. New data from the CDC show the number of US youth who used electronic cigarettes, but have never smoked a regular cigarette, has more than tripled in the past 3 years—from 79,000 in 2011 to over 263,000 in 2013. These youth are nearly twice as likely to intend to smoke regular cigarettes as those who have never used e-cigarettes.

Deaths from cardiovascular disease have declined steadily since the late 1960s, almost in parallel with the decline in rates of tobacco use, yet tobacco still accounts annually for nearly 6 million deaths worldwide and 400,000 deaths in the United States. While the idea of a safe cigarette and an effective smoking cessation aid is appealing, it is not reasonable to assume without more evidence that “vaping,” a common term for inhaling the chemical aerosol from e-cigarettes, is better than smoking. E-cigarettes, even though most contain an addictive drug, are not regulated like the FDA-approved nicotine-based smoking cessation products. In fact, makers of e-cigarette liquid cartridges are not required to disclose their ingredients.

Reports of exposure to dangerous levels of nicotine from e-cigarettes are on the rise. The CDC reported that calls to poison control centers related to e-cigarettes had risen to 200 per month in the first quarter of 2014, with more than half of the calls involving children under the age of 5. As someone who closely watches medical research, I find that it’s not unusual to see promising new technologies or treatments appear on the landscape, but when the actual long-term outcomes are studied, we learn that the promising new thing is no better—and maybe even worse—in real life. This was the case with low-tar cigarettes. When machines were used to test low-tar cigarettes, the mechanical “smokers” inhaled less tar suggesting the low-tar cigarettes were safer for people. But it turned out human smokers smoke differently than machines, and smokers of low-tar cigarettes fared as bad or worse in the long term than smokers of regular cigarettes.

We should not be experimenting with an addictive drug on a new generation of “vapers,” who may think this is a safe alternative to smoking. We should instead continue to reduce the burden of cardiovascular disease and cancer by continuing to de-normalize smoking. To that end, the ACC strongly believes that the FDA should regulate e-cigarettes to the full extent of the authority granted to it by the Family Smoking Prevention and Tobacco Control Act of 2009, including requiring manufacturers to submit applications for approval that contain rigorous scientific evidence of product safety. The College is working with the Campaign for Tobacco-Free Kids, our ACC state chapters, the American Medical Association and other stakeholders, to urge the FDA to use the fullest extent of its authority to regulate tobacco products and to restrict their availability to minors.

Share your thoughts on this topic on the ACC in Touch Blog at blog.CardioSource.org.

Patrick O’Gara, MD, FACC, is the current ACC president.

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