Even though nicotine is not present in E-cigarettes, ingredients in vaping products, particularly flavoring agents, independently carry risks.
A recent scientific statement published in the journal Circulation by the American Heart Association highlights the growing body of research uncovering the health risks associated with e-cigarette use. The statement emphasizes the urgent need for further studies to better understand the long-term impact of e-cigarettes on heart and lung health.
E-cigarettes, also known as vaping products, are battery-operated devices that heat a liquid solution called e-liquid, generating an aerosol that users inhale into their lungs. Most e-liquids contain nicotine, a substance known to have adverse health effects and addictive properties. Additionally, these products may contain other substances such as tetrahydrocannabinol (THC), the psychoactive component of cannabis, as well as methamphetamine, methadone, vitamins, metals from heating coils, and various chemicals.
Dr. Jason J. Rose, the volunteer chair of the scientific statement writing committee, warns that e-cigarettes introduce numerous potentially harmful substances into the body, including chemicals that users may not be aware of or understand. Research indicates that e-cigarettes containing nicotine can lead to acute changes in blood pressure and heart rate. Moreover, even nicotine-free e-cigarettes, particularly those with flavoring agents, have independent risks associated with heart and lung diseases, as evidenced by animal studies and research on individuals exposed to commercially available products.
The statement underscores the importance of the clinical diagnosis known as “E-cigarette, or Vaping, product use Associated Lung Injury” (EVALI). This condition was officially recognized by the U.S. Centers for Disease Control and Prevention in 2019 when approximately 2,800 e-cigarette users were hospitalized within a year. EVALI serves as an example highlighting the limited knowledge surrounding e-cigarette risks and ingredients. In the case of EVALI, vitamin E acetate, used as a thickening agent in some e-cigarette liquids, was identified as the likely causative ingredient.
Research on the specific impact of e-cigarettes on heart attacks and strokes is currently limited, often conducted in individuals who have used or are using traditional cigarettes. Large survey studies primarily focus on young adults with a low incidence of heart attacks and strokes. To gain a comprehensive understanding of the health effects, the writing committee calls for long-term studies involving e-cigarette users of all ages, including those with pre-existing cardiovascular disease.
According to recent analyses of the Population Assessment of Tobacco and Health (PATH) study, there is a statistically significant association between former or current e-cigarette use and the development of respiratory diseases within two years. This ongoing study, initiated in 2013 by the National Institutes of Health and the U.S. Food and Drug Administration, highlights the rapid increase in e-cigarette use since 2010, primarily among current or former cigarette smokers. Furthermore, data from the Behavioral Risk Factor Surveillance System reveals that by 2016, approximately 1.2 million adults in the U.S. who had never smoked traditional cigarettes were using e-cigarettes.
The statement emphasizes that e-cigarettes are the most commonly used tobacco products among young people, particularly high school and middle school students. Nearly three-quarters of young e-cigarette users exclusively consume flavored products. The prevalence of e-cigarette use among youth underscores the need to assess both short- and long-term health effects.
Dr. Rose explains that young individuals are attracted to the enticing flavors available in e-cigarettes, which can lead to nicotine addiction. There is a significant concern that young people perceive e-cigarettes as harmless due to their wide availability and marketing directed at their age group, many of whom have never used any tobacco products. Additionally, studies show a correlation between e-cigarette use and substance use disorders, as some young users transition to other tobacco products.
While e-cigarette products have been evaluated as smoking cessation tools, the scientific statement cautions that the limited research in this area does not provide strong evidence supporting their efficacy beyond short-term benefits. The known and unknown health risks associated with e-cigarettes, including the potential for long-term dependence, must be weighed against any potential benefits. The American Heart Association, therefore, does not recommend e-cigarette use for cessation efforts. The statement advises a combination of multiple-episode cessation counseling, personalized nicotine replacement therapy using FDA-approved doses and formulations, and medications to control cravings for individuals attempting to quit combustible cigarettes.
“E-cigarette companies have suggested that their products are a way to quit smoking traditional cigarettes,” said Rose Marie Robertson, M.D., FAHA, the Association’s deputy chief science and medical officer and co-director of the Association’s Tobacco Center of Regulatory Science.
“There is no strong evidence to support this beyond any short-term benefit. The lack of long-term scientific safety data on e-cigarette use, along with the potential for the addiction to e-cigarette products seen among youth, are among the reasons the American Heart Association does not recommend e-cigarette use for cessation efforts.”
It is crucial to recognize that e-cigarette products have not received approval from the U.S. Food and Drug Administration (FDA) for tobacco cessation purposes. Instead, the American Heart Association suggests a comprehensive approach to help individuals who smoke traditional cigarettes quit successfully. This approach involves multiple-episode cessation counseling, along with personalized nicotine replacement therapy using FDA-approved doses and formulations. Additionally, medications can be utilized to aid in controlling cravings. It is important to acknowledge that the quitting process often requires multiple attempts, and any setbacks should be viewed as opportunities to learn and progress toward overcoming the powerful addiction for good.
The writing committee underscores the critical need for additional research and knowledge in several areas, including:
- Investigation of the serious and potentially long-term effects of e-cigarettes on the heart, blood vessels, and lungs.
- Studies involving patients with pre-existing cardiovascular or pulmonary diseases to compare outcomes among e-cigarette users, traditional smokers, dual users (those using both e-cigarettes and traditional cigarettes), and nonsmokers.
- In-depth research on the chemical ingredients commonly found in e-cigarettes and their independent effects on pulmonary and cardiac health.
- Clinical studies to assess the risks and potential benefits of e-cigarettes as alternatives to traditional combustible cigarettes.
- Molecular and laboratory studies to examine the biological implications of e-cigarette use while waiting for long-term health impact assessments, as the emergence of these effects may take decades.
- Expanding research efforts to include the exponential adoption of e-cigarettes, especially among young people with no prior combustible cigarette use.
“Because e-cigarettes and other vaping systems have only been in the U.S. for about 15 years, we do not yet have enough information on their long-term health effects, so we must rely on shorter term studies, molecular experiments and research in animals to try to assess the true risk of using e-cigarettes,” noted Jason Rose. “It is necessary for us to expand this type of research since the adoption of e-cigarettes has grown exponentially, especially in young people, many of whom may have never used combustible cigarettes.”
The scientific statement was prepared by a volunteer writing group representing various councils of the American Heart Association. While scientific statements inform the development of guidelines, they do not provide treatment recommendations. Their purpose is to increase awareness about cardiovascular diseases and aid informed healthcare decision-making.
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