Perspective:

The following are 10 points to remember about this policy statement on electronic cigarettes (e-cigarettes) from the American Heart Association (AHA):

1. Use of e-cigarettes has increased significantly over recent years. As such, the AHA recognized a need for a clear policy position regarding the use of e-cigarettes. The AHA considers e-cigarettes that contain nicotine to be tobacco products, and therefore, supports their regulation under existing laws relating to the use and marketing of tobacco products.

2. E-cigarettes have lower levels of several tobacco-derived harmful and potentially harmful constituents compared with cigarettes and smokeless tobacco. However, little is known regarding the long-term use of e-cigarettes. Therefore, the AHA supports effective regulation that addresses marketing, labeling, quality control of manufacturing, and standards for contaminants.

3. Use of e-cigarettes may be an opportunity for cigarette smokers to use e-cigarettes as substitutes for regular cigarettes. This may reduce harm to the smoker and those exposed to secondhand smoke. Concern exists that use of e-cigarettes has the potential to renormalize smoking behavior. Most e-cigarette users report being current cigarette smokers. However, it is unclear how many smokers are using e-cigarettes to assist with smoking cessation, are ex-smokers, or are using both (cigarettes and e-cigarettes).

4. An estimated 1.78 million US middle and high school children and adolescents have tried e-cigarettes. To prevent the potential negative public health impact of e-cigarettes, the AHA strongly supports laws and regulation that prohibit the sale and marketing of e-cigarettes to youth.

5. Currently, e-cigarettes vary in the dose of nicotine delivered; however, in general, the level of nicotine absorbed is less than conventional cigarettes. Potential to regulate nicotine content in both e-cigarettes and conventional cigarettes may be part of a public health strategy for reducing smoking in the United States.

6. Typically, e-liquid formulations contain nicotine, flavors, water, glycerin, and propylene glycol. Exposure to levels and types of metals or other materials within the aerosol depends on the material and other engineering features of the heating coils. Potential metallic and nanoparticles derived from the heating coils can include tin, iron, nickel, and chromium.

7. Currently, the data on health effects, studied primarily in healthy people with short-term exposure, reveal little or no evidence of severe adverse events. Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and chronic obstructive pulmonary disease; however, one small study reports no harm, but rather benefit, when users quit smoking or smoke fewer cigarettes per day. There are no reports of e-cigarette safety in patients with known cardiovascular disease.

8. Most of the secondhand smoke generated from conventional cigarettes results from side-stream smoke, which accounts for 75% of the burning cigarette mass. E-cigarettes do not generate side-stream aerosol. The secondhand emissions from e-cigarettes consist entirely of what is exhaled after inhalation by the user.

9. Secondhand exposure to e-cigarette aerosol does expose a nonsmoker to nicotine, particulates, and several potentially toxic organic chemicals, but at much lower levels than from conventional cigarette smoke. The biological effects of such an exposure are expected to be much less than that of secondhand smoke, but the long-term effects of such exposure are unknown. The AHA supports the inclusion of e-cigarettes in smoke-free air laws.

10. The AHA maintains that e-cigarette use should be part of tobacco screening questions incorporated into clinical visits and worksite/community health screenings that are tied to healthcare delivery. Clinicians should be educated about e-cigarettes and should be prepared to counsel their patients regarding comprehensive tobacco cessation strategies. There is not yet enough evidence for clinicians to counsel their patients who are using combustible tobacco products to use e-cigarettes as a primary cessation aid.