In the most comprehensive study yet of the growing body of research into e-cigarettes, the American Heart Association said Monday that it is reasonable for doctors to recommend the increasingly popular devices to stop smoking, but only if recognized methods such as nicotine patches fail and a patient wants to try e-cigarettes.
It also said e-cigarettes may be safer than traditional cigarettes, but they still pose an array of potential risks and should be the focus of more taxes, regulations and research.
The formal policy, the association’s first on e-cigarettes, was developed by a team of researchers including Kurt Ribisl, a professor of health behavior at UNC-Chapel Hill’s Gillings School of Global Public Health.
E-cigarettes are battery-powered devices that heat a liquid, usually containing the tobacco-derived stimulant nicotine, into a vapor, which users then inhale.
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They have been on the U.S. market little more than a decade but are already a $2 billion business. Some industry analysts think they could eclipse traditional cigarette smoking in the next decade.
The association’s new policy reflects not only the fact that research into e-cigarettes lags the industry’s soaring sales numbers, but also the vigorous debate over how much emphasis to place on e-cigarettes as an alternative to traditional smoking or an aid to help people quit.
Dr. Elliott Antman, president of the American Heart Association, said the policy underlines the facts that there still aren’t adequate research and regulations to ensure that e-cigarette users know what’s in the vapor they are inhaling and what dangers it poses.
The new policy encourages more research in a host of areas, including long-term studies of e-cigarette use, deeper investigation into how they are marketed and their long-term health effects.
“In the meantime, we should stop marketing them to youth(s), regulate them properly and put them under smoke-free regulations,” Antman said.
The policy says that using e-cigarettes should be discouraged, except as a potential tool of last-resort to help smokers stop.
Its recommendations include classifying them as tobacco products so that they can be better regulated, and in particular so that they can be included in current smoke-free laws.
Among other things, it also calls for setting taxes on e-cigarettes high enough to discourage their use, particularly among youths – but not so much that they become unattractive as that potential last resort for smokers trying to quit. It says taxes on traditional combustible tobacco products should be increased to further discourage their use.
North Carolina impact
In North Carolina, the policy’s implications go beyond people who use the devices. One of the nation’s largest producers of e-cigarettes is located here, Winston-Salem-based Reynolds American Inc. Its e-cigarette subsidiary, R.J. Reynolds Vapor Co., went national this summer with its brand, Vuse.
Richard J. Smith, a spokesman for Reynolds American, said in emailed statements that since the company does not market Vuse as a cessation aid it wouldn’t comment on the parts of the policy regarding that. It does believe, though, that e-cigarettes should not be treated the same as tobacco products, and that any tax on them should be reasonable. He cited North Carolina’s as a good example.
State leaders approved a 5-cent-per-milliliter tax on the liquid solution used to make the vapor.
It’s hard to make direct comparisons, in part because the nicotine level can vary widely in this “juice,” but 1 milliliter is often compared to a pack of cigarettes, which is taxed by the state at 45 cents.
“Vapor products do not contain tobacco leaf; they are not burned; they do not produce smoke or secondhand smoke,” Smith wrote. “Any tax considered on vapor products should not be at a rate that might deter current adult smokers from considering switching to smoke-free alternative products like the VUSE Digital Vapor Cigarette. An excessive tax could hurt this relatively new business, one that has great promise and is producing jobs in North Carolina.”
Ribisl said that while it’s good that there is a difference between the e-cigarette and traditional taxes here, the e-cigarette tax was set too low to discourage use of the device. Many states haven’t even tackled the topic yet, and they should aim higher, he said.
“For a state that has not yet taxed e-cigarettes, they should enact a tax and it should be at a high enough rate to discourage youth from starting to use e-cigarettes,” Ribisl said. “They also should tax them at a lower rate than cigarettes and other combusted products.”
The American Heart Association policy also notes that e-cigarettes don’t contain many of the harmful ingredients in traditional cigarettes, or have them in lower levels. In particular, it cites tobacco-specific nitrosamines, which are highly carcinogenic but are found in such small amounts in most e-cigarettes that they are unlikely to pose a significant risk.
The policy also catalogs the various worries that the lack of hard data has allowed to flourish. Among them are concerns that e-cigarette use and acceptance could “renormalize” regular smoking; sustain dual use of both products by some people; start and maintain nicotine addiction; serve as a gateway for people to begin smoking again; and potentially erode smoke-free laws.
In effect, it also says that the association will keep an eye on things as more science emerges.
“We will continue to assess the scientific evidence relating to their long-term health effects and their efficacy as a smoking cessation aid and encourage the development of a robust research agenda to understand the public health impact of e-cigarettes, especially in at-risk populations,” the policy says.