E-cigarettes - a cardiovascular health concern

The role and impact of electronic cigarettes continues to provoke a major public health debate in Europe and beyond.

EHN’s newest paper on e-cigarettes has a focus on the effects of e-cigarette use on the cardiovascular system. It also presents information on trends in the use of e-cigarettes, as well as marketing and regulation, and it discusses the distinction between absolute and relative risk.

The Findings

• Whereas short-term e-cigarette use may be less harmful to the cardiovascular system than smoking conventional cigarettes, the long-term effects are unknown. The lack of evidence for the long-term effects, however, cannot be interpreted as no effect.
• E-cigarettes are promoted as risk-reducing products compared to combustible tobacco cigarettes, and there is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes. But combustible tobacco cigarettes are arguably the most dangerous products that can be bought legally, and while e-cigarettes lack tar, one of the most toxic and extensively studied components of cigarettes, they do produce toxic substances, mainly flavours, not found in cigarettes, that are much less well understood. Moreover, a majority of e-cigarette users continue to smoke combustible tobacco cigarettes. These dual users (of e-cigarettes and combustible tobacco cigarettes) will not reduce their health risks. They may even increase them.
• A key benefit of e-cigarettes for both individuals and for public health would be to aid smoking cessation among people who smoke conventional cigarettes. However, there is not sufficient evidence that e-cigarettes actually are effective as a smoking cessation aid.
• People, and in particular young people who have never smoked, are increasingly taking up e-cigarette use. This is also the case for those who previously quit smoking. Both groups are at substantial risk of (re-)starting smoking, all the more so, since certain flavours in e-cigarettes are specifically attractive to children and young people.
• When looking at e-cigarettes, interpreting the evidence of level of risk is complicated by extensive conflicts of interest. 95% of papers that did not involve conflicts of interest found potentially harmful effects of e-cigarettes. On the other hand, industry-related conflict of interest was strongly associated with finding of no harm.
• When evaluating the pros and cons of e-cigarettes, it is important to consider their impact on the whole population, not only on smokers, who are a minority. From a public health point of view, these products may have an unfavourable net effect, especially because of rising uptake by never smokers.
• Based on the evidence that is currently available, it can be concluded that e-cigarette use is of real cardiovascular health concern. Considering the very high burden of cardiovascular disease in Europe, the mere possibility that e-cigarette use increases the risk of cardiovascular disease is a cause of concern.

EHN’s recommendations for policy makers and health professionals:

• There is a need for longitudinal studies to elucidate the long-term effects of e-cigarette use on the cardiovascular system and whether e-cigarette use is less hazardous to cardiovascular health than conventional cigarette smoking in the longer term.
• Medical journals should refrain from publishing studies that are partly or fully funded by entities that have an industry-related conflict of interest.
• Health professionals should inform patients and the public of the risks related to e-cigarette use.
• Flavours should be prohibited. This should certainly be the case for those flavours that may not be safe and those that are likely to attract children and young people.
• The same buying restrictions and age limits should be set for e-cigarettes as for conventional cigarettes.
• Restrictions on marketing, including advertising, labelling and packaging, of e-cigarettes should be the same as for conventional cigarettes.
• The use of e-cigarettes in public places should be prohibited. Given the fact that second-hand exposure has some impact on bystanders’ health, that use of e-cigarettes may make it more complicated to enforce smoke-free legislation, and that use of e-cigarettes may change the norm in terms of use of conventional cigarettes in public places, e-cigarette use in public places should be prohibited.
• Tax measures should be used as appropriate: applying a special excise duty or tax on e-cigarettes has the dual benefit of discouraging use – especially for young people – and raising income for governments. EHN recommends taxing e-cigarettes at a rate high enough to discourage uptake.