American Heart Association supports e-cigarettes for quitting tobacco

The American Heart Association circulated its official policy recommendation on electronic cigarettes Monday, saying that e-cigarettes can be can be used to quit smoking tobacco, but only as a last resort.

The association added that electronic cigarettes should be regulated in the same way as tobacco products, meaning stricter advertising restrictions and a ban on selling to minors. “We also support the inclusion of e-cigarettes in smoke-free air laws,” it said in its position paper, published in the journal Circulation.

“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,” Nancy Brown, chief executive officer of the American Heart Association, said in a news release. “These disturbing developments have helped convince the association that e-cigarettes need to be strongly regulated, thoroughly researched and closely monitored.”

The heart association said evidence that e-cigarettes help smokers quit is “sparse.” They cited the few controlled studies and said they showed a “modest effect” on quitting, about equal to or slightly better than nicotine patches.

If a patient has “failed initial treatment” or does not want to use other means such as nicotine patches, “it is reasonable to support the attempt” of using e-cigarettes, the association said. It added that patients should be told that e-cigarettes, while far less toxic than tobacco cigarettes, are unregulated and “have not been proven as cessation devices.”

Electronic cigarettes are battery-powered devices that use an atomizer to heat a nicotine-laced solution into a vapor for the smoker to inhale, or “vape,” as users have dubbed it.

After first entering the United States in 2007 from Asia, their popularity has exploded into an estimated  $2 billion in global e-cigarette sales, according to consumer analysis firm Euromonitor International.

As a relatively new product, e-cigarettes do not face the same stringent regulations that were eventually placed on tobacco products after scientists linked them to cancer and heart disease. While traditional cigarettes are banned from TV ads, cannot be sold to minors and come with warning labels, e-cigarettes are hawked on television by celebrities as alternatives to regular cigarettes. 

The World Health Organization warned last year that the safety of e-cigarettes has not been scientifically demonstrated. It said it is reviewing the existing research and will come up with an updated conclusion later this year.

The U.S. Food and Drug Administration in 2011 announced its intent to regulate e-cigarettes the same way it does tobacco products, and in April proposed a rule that makers of new e-cigarette brands would be subject to tobacco regulation. Some U.S. cities including New York have banned e-cigarettes indoors and in parks, and the Department of Transportation has banned them on planes.

Most experts agree that e-cigarettes should be more heavily regulated, but they are divided as to the devices’ potential effectiveness in helping people quit. While some experts cite the many fans of e-cigarettes who have reported quitting tobacco, others fear it could help normalize smoking again.

“We have to look at the science, and what the science tells us is that there are many, many smokers who say they are a very effective method for actually getting them to quit smoking,” said Dr. Michael Siegel, a professor of community health sciences at Boston University’s School of Public Health. “There are literally thousands of ex-smokers out there who have quit using electronic cigarettes, many of them who did not think they would be successful.”

The major benefit, Siegel said, is that unlike nicotine patches, e-cigarettes actually simulate the smoking of a cigarette — but he thinks that aspect is what fuels their detractors. “There’s no reason we should exclude them or not recommend them simply because we’re fearful of them because they look like cigarettes,” he said. “The fact is, that’s what makes them so effective.”

But the Centers for Disease Control has cautioned that electronic cigarettes could function as a “gateway” to smoking. On Monday, it released new data showing that a quarter-million U.S. middle and high school kids who had never smoked a cigarette had smoked e-cigarettes in 2013, triple the number who said the same in 2011, according to its annual National Youth Tobacco Surveys.

But according to Maciej Goniewicz, an oncology professor at the Roswell Park Cancer Institute in Buffalo, N.Y. who has studied the ingredients and teenage use patterns of e-cigarettes, the gateway theory has not been clearly established.

While he admits that electronic cigarettes are becoming more and more popular, and are certainly very visible to kids and teens, “I’m not sure if we can clearly say this is a gateway” to regular tobacco smoking, he said. “Right now, I’d say there is a danger, or some evidence, and I think we have to be very careful.”

“Right now we are gaining more and more evidence that [e-cigarettes] might be a problem," he added. "But we still don’t have a clear link between the electronic cigarettes and the initiation of smoking.”