AHA Urges Caution on E-Cigarettes, Citing Lack of Good Data

Since their introduction a little over a decade ago, electronic cigarettes have exploded onto the marketplace, quickly evolving from a novelty item to a ubiquitous presence. The popularity of these products, though, is far outpacing related research and regulation.

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On August 25, the American Heart Association (AHA) provided some needed information and guidance through the organization’s first policy statement on e-cigarettes.

While scientific studies into e-cigarettes are limited, the AHA panel went through the evidence to develop recommendations in several key areas of e-cigarette control such as clean indoor air laws, taxation, regulation, targeting of products to youth, surveillance, and smoking cessation.

One of the key conclusions was that the AHA does not support e-cigarettes as a primary aid in smoking cessation. The statement noted a lack of empirical evidence that e-cigarettes are more effective or safer than other available options. Some observational and survey studies have suggested that e-cigarettes can improve quit rates, but the one large randomized study completed to date found them to be only as effective as a nicotine patch after six months, with a similar rate of side effects.

The AHA policy did add that in cases in which repeated efforts with conventional treatments fail, are not well-tolerated, or rejected by a patient, clinicians should not discourage e-cigarettes if the patient requests them. The message that e-cigarettes are a contingency plan for quitting gained traction in the media, but as Douglas Ziedonis, M.D., M.P.H., chair of the Department of Psychiatry at the University of Massachusetts Medical School, believes, it does muddle the issue of what e-cigarettes are.

“Obviously, if a patient comes to you and says ‘I want to use e-cigarettes,’ which are available over the counter, you can’t say no,” Ziedonis told Psychiatric News. “However, it’s important to remember that e-cigarette manufacturers are not making any therapeutic claims, nor is the Food and Drug Administration aiming to classify them as a medication.”

In April, the FDA proposed to extend its regulatory authority over tobacco products to include e-cigarettes and some other devices (Psychiatric News, May 29), but these rules are not scheduled to be finalized until June 2015.

The better take-home message from the current knowledge of e-cigarettes, Ziedonis suggested, is one that stresses dialogue. “We need to make sure to ask patients about e-cigarettes. ‘How often do you use e-cigarettes? In what settings? Do you use them in addition to other tobacco products?’ We can then integrate that knowledge into a cessation strategy that makes use of approved medications and social support,” he said.

The AHA stated that this policy is provisional; the organization will continue to monitor the e-cigarette landscape and evolve its position as new data become available. In the meantime, the current statement offers a resource for people to educate themselves about numerous e-cigarette topics beyond just their role in a smoking-cessation strategy, including their design, toxicology, and health impact.

“Given the high prevalence of tobacco use among people with mental illness, especially teens and young adults, I believe these guidelines are worthwhile reading for any psychiatrist,” Ziedonis said. ■