p0903-athlete-tobacco.pdf

p0930-flavored-tobacco.pdf

infographic-ecigs2.pdf

infographic-ecigs.pdf

p0425-CDC-ecig-marketing.pdf

tobacco-use-teens-2019-p.pdf

parent-teacher-ecig-508.pdf

Here is what we do NOT know

Whether e-cigs help smokers quit. There are some anecdotal stories of ex-smokers who could not quit until they tried e-cigarettes, but there is no substantiating research yet to corroborate this claim.

The impact on children. According to the CDC the number of teenagers using e-cigs has doubled. Are kids now becoming nicotine addicts without ever picking up a cigarette? Will some of them switch to regular cigarettes at a later stage? We don’t know enough about what impact e-cigs have on initiation into nicotine addiction.

The contents of the vapor. The marketing is aimed at making consumers think e-cigarettes just emit water vapor, but they do not. There is some strong evidence that the vapor contains toxins and carcinogens, and because there are dozens of unregulated manufacturers, it is impossible to know what exactly is being inhaled by the people who are exposed to vapor from e-cigarette users.

The health impact on users. Without knowing their ingredients, we cannot know the health effects that result from e-cigarette usage or exposure. While e-cigarette companies claim they are safe, they have no scientific evidence to corroborate this claim either.

Here is what we DO know

E-cigarettes are aggressively marketed to children, with flavors like bubble gum and cotton candy. The marketing is disturbingly similar to past cigarette marketing that is now illegal.

E-cigarettes are nicotine delivery devices. Nicotine is highly addictive, according to the National Institute of Drug Abuse (NIDA) – http://www.drugabuse.gov/publications/research-reports/tobacco-addiction/nicotine-addictive.

The Food and Drug Administration is researching e-cigarettes in order to determine safe and necessary regulations (like all other products we ingest), but no official government regulations can be expected for at least three years.

Here is ASH’s stance

If e-cigarettes are safe, the e-cig companies should prove it. At present, they are in the business of selling an addictive drug, and they are targeting children. For now, while the safety of e-cigs remains in doubt, they should be s treated like cigarettes. This means:

• No “vaping” in places that ban smoking;
• No advertisements on television, radio, or billboards;
• No marketing to children whatsoever;
• No sales to children, with procedures in place to prevent children from buying e-cigs on the Internet;
• No misleading health claims.

Utah, North Dakota, New York City, and other governments in the U.S. and abroad already regulate e-cigarettes, and ASH encourages all jurisdictions to do the same. We, along with many other public health and regulatory organizations, also urge the FDA to move as quickly as possible to regulate e-cigarettes at the national level and to protect the health of everyone.

Additional Information

The FDA on e-cigarettes:
http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm

The World Health Organization (WHO) on e-cigarettes: http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/

Studies on E-Cigarettes
- E-Cig Briefing Paper
- http://www.fda.gov/%20NewsEvents/Newsroom/PressAnnouncements/ucm173222.htm
- http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm?s_cid=mm6235a6_w
- http://www.dkfz.de/en/presse/download/RS-Vol19-E-Cigarettes-EN.pdf
- http://www.hsph.harvard.edu/news/hsph-in-the-news/tobacco-control-news-ecigarette-risks-greek-rates-decline/
- http://tobacco.ucsf.edu/e-cigarettes-release-toxic-chemicals-indoors-should-be-included-clean-indoor-air-laws-and-policies
- http://legacyforhealth.org/newsroom/press-releases/new-study-investigates-online-tobacco-and-e-cigarette-advertising

E-Cigarettes in the News
- 45 State Attorneys General Call for Tobacco Carve Out
- Dangers of E-Cigs
- Chicago Bans Indoor E-Cigs
- New York City Bans Indoor E-Cigs
- A Hot Debate Over E-Cigarettes as a Path to Tobacco, or From It
- Utah Bans E-Cigs like Cigarettes

This article originally appeared on http://ash.org

By Jacqueline Howard and Michael Nedelman, CNN

Updated 5:06 PM ET, Fri September 13, 2019

https://www.cnn.com/2019/09/11/health/vaping-lung-illness-illinois-teen-profile/index.html

(CNN)Adam Hergenreder's vaping habit almost killed him.

Late last month, the 18-year-old student athlete in Gurnee, Illinois, was hospitalized after using e-cigarettes for more than a year and a half. Now his lungs are similar to those of a 70-year-old adult, doctors told him.

"It was scary to think about that -- that little device did that to my lungs," Adam said, remembering the news from his doctors about his lung health.

Adam is among the hundreds of e-cigarette users in the United States who have been sickened with mysterious vaping-related lung illnesses, many of them young people. Investigators haven't yet identified the cause of the illnesses.

Amid calls for more regulation, the Trump administration now plans to remove flavored e-cigarettes -- except tobacco flavor -- from the marketplace.

"Why is that important? We are seeing an absolute surge in high school and middle school kids using these flavored products," US Health and Human Services Secretary Alex Azar said in a video statement on Wednesday. "Mint, menthol, fruit flavor, alcohol flavor, bubble gum."

The US Food and Drug Administration announced on Wednesday that more than a quarter of high school students this year have reported using e-cigarettes and the "overwhelming majority" reference using popular fruit and menthol or mint flavors, according to preliminary data from the National Youth Tobacco Survey.

Adam, who vaped nicotine and THC products, said he isn't sure his lungs will ever be back at 100% -- and he worries whether he will ever be able to wrestle again.

"I was a varsity wrestler before this and I might not ever be able to wrestle because that's a very physical sport and my lungs might not be able to hold that exertion. ... It's sad," Adam said.

'We must act swiftly'

There are more than 450 possible cases of lung illness associated with using e-cigarettes across the United States, according to the US Centers for Disease Control and Prevention, which has called this an "outbreak."

Health officials have also confirmed six deaths -- in California, Illinois, Indiana, Minnesota, Oregon and Kansas -- in connection to vaping-related lung illnesses.

While the illnesses and deaths have occurred in both young people and older adults, experts have warned of a rise in vaping among youth.

"We must act swiftly against flavored e-cigarette products that are especially attractive to children," Acting FDA Commissioner Dr. Ned Sharpless said in the announcement, adding that the FDA will take additional steps to address youth use of tobacco-flavored products still on the market, if young people begin to use them.

"The tremendous progress we've made in reducing youth tobacco use in the US is jeopardized by this onslaught of e-cigarette use. Nobody wants to see children becoming addicted to nicotine, and we will continue to use the full scope of our regulatory authority thoughtfully and thoroughly to tackle this mounting public health crisis."

Separate surveys also suggest that most teens think e-cigarettes are safe.

Adam certainly thought vaping was safe when he started using e-cigarettes, he said. One of his favorite flavors was mango.

"It didn't taste like a cigarette," he said. "It tasted good," and provided a little buzz due to the nicotine.

The vaping began about a year and a half ago, he said, and he would pick up e-cigarette products, such as those of the Juul brand, from his neighborhood gas station.

"They didn't card me," he said.

"He would wake up in the morning and would puff on that Juul and then cough," said Adam's mother, Polly Hergenreder.

"He would hit it several times throughout the day. My son was going through a pod and a half every other day, or a day and a half."

Experts say that one Juul pod -- a cartridge of nicotine-rich liquid that users plug into the dominant e-cig brand -- delivers the same amount of nicotine to the body as a pack of cigarettes. "That's smoking a lot of cigarettes," Polly said.

Eventually, Adam said that he went from vaping over-the-counter e-liquids to vaping THC or tetrahydrocannabinol, which is the main psychoactive component of marijuana. Adam would get the THC from "a friend" or dealer.

Over time, Adam said that he developed shivers and couldn't control them. Then, the vomiting began.

"I was just nonstop throwing up every day for three days," he said. "Finally I went to the pediatrician."

At first, doctors did not connect Adam's symptoms to his vaping. He was given anti-nausea medication, but he said that his vomiting did not stop. After visiting various physicians, he finally saw someone who asked if he was "Juul-ing" and using THC.

"I answered honestly," Adam said. "I said I was."

The team overseeing Adam's care performed a CT scan of his stomach and noticed something unusual about the lower portion of his lungs. The doctors then took an X-ray of his lungs.

"That's when they saw the full damage," Adam said.

"If I had known what it was doing to my body, I would have never even touched it, but I didn't know," he said about vaping. "I wasn't educated."

'If we did not bring Adam in ... his lungs would have collapsed'

Adam was admitted to the hospital in late August.

"If his mom had not brought him to the hospital within the next two to three days, his breathing could have worsened to the point that he could have died if he didn't seek medical care," said Dr. Stephen Amesbury, a pulmonologist and critical care physician at Advocate Condell Medical Center in Illinois, who was one of the doctors who saw Adam.

"It was severe lung disease, especially for a young person. He was short of breath, he was breathing heavily," Amesbury said. "It was very concerning that he would have significant lung damage and possibly some residual changes after he heals from this."

Adam's mother Polly spent the following six days in the hospital with her son, who was connected to IVs and was provided oxygen through nasal tubes.

"The doctors did tell us that if we did not bring Adam in when we brought him in, his lungs would have collapsed and he would have died," Polly said.

Yet, she added, "you should always try to find the silver lining," and for her family, that is to use Adam's experience to educate others about the risks of vaping.

Adam is now home from the hospital and "it's still difficult to even do normal activities, like going upstairs. I still get winded from that," he said.

Even though he is still recovering -- including doing breathing treatments -- Adam has focused on sharing his story. Through his advocacy, he said that he has even convinced some of his friends to stop vaping.

"I'm getting better each day," he said. "I don't want to see anybody in my situation. I don't want to see anybody in the hospital for as long as I was."

Lawsuit filed

On Friday, Adam filed a lawsuit against Juul Labs and the gas station that allegedly sold him Juul products when he was underage.

The lawsuit alleges Juul "sought to fill the void left by big tobacco by creating a new-age electronic cigarette." By using social media, the lawsuit alleges, "JUUL was able to easily target and manipulate youth by using advertisements designed to fulfill powerful psychological needs like popularity, peer acceptance, and a positive self-image -- the same techniques used by big tobacco in decades past."

In a statement, Antonio Romanucci, an attorney at Romanucci & Blandin, the firm that filed the lawsuit, said, "To put it mildly, Adam didn't stand a chance to avoid getting hooked on these toxic timebombs."

In response to the lawsuit, Ted Kwong, a spokesperson for Juul Labs, said the company is committed to eliminating combustible cigarettes, and that its product is intended to be a "viable alternative" for adult smokers.

"We have never marketed to youth and do not want any non-nicotine users to try our products. We have launched an aggressive action plan to combat underage use as it is antithetical to our mission," the statement said, including halting the sale of non-tobacco and non-menthol-based flavors in traditional retail stores, enhancing online age verification and shutting down its Facebook and Instagram accounts, among other steps.

"It was our hope that others in the category would self-impose similar restrictions to address youth usage," the statement said.

There really isn't enough vaping history to say what's going to happen'

The federal investigation into the link between vaping and severe lung illnesses is ongoing and has not identified a cause, but all reported cases have indicated the use of e-cigarette products and some patients have reported using e-cigarettes containing cannabinoid products, such as THC.

There are also separate investigations being conducted in separate states.

New York health officials said last week that extremely high levels of the chemical vitamin E acetate were found in nearly all cannabis-containing vaping products that were analyzed as part of the investigation. At least one vape product containing this chemical has been linked to each person who fell ill and submitted a product for testing in the state.

Laboratory tests conducted at the New York State Department of Health's Wadsworth Center in Albany showed "very high levels" of vitamin E acetate in the cannabis-containing samples, the state health department announced.

Vitamin E acetate is now "a key focus" of the state's investigation into the illnesses, the New York Department of Health said. Some of the products that have been found to contain vitamin E acetate are candy-flavored vapes.

Juul has maintained that its products are intended to convert adult smokers to what it described in the past as a less-harmful alternative. In other communications, the company says it cannot make claims its products are safer, in line with FDA regulations.

Scientists point out that they are still learning about the long-term health effects of e-cigarettes. One study published in the Journal of the American College of Cardiology in May found that e-cigarette flavors can damage the cells that line your blood vessels and perhaps your heart health down the line.

Another study, published in the journal Radiology in August, foud that vaping temporarily impacts blood vessel function in healthy people. Using MRI scans, it found, for example, changes in blood flow within the femoral artery in the leg after just one use. The researchers couldn't determine which chemical might be responsible for the changes they observed.

There are many questions that remain to be answered, according to Amesbury.

"We're very early in the stages of finding out what problems may come up from vaping," he said. "We're finding these acute, severe illnesses now, but there really isn't enough vaping history to say what's going to happen 10, 20, 30 years down the road."

CNN's Michael Nedelman and Arman Azad contributed to this report.

By Chuck Johnston and Hollie Silverman, CNN

Updated 4:19 PM ET, Tue September 17, 2019

https://www.cnn.com/2019/09/17/health/seventh-vaping-related-death-california/index.html

(CNN)A California man has become the seventh person to die from a vaping-related illness in the United States as the nation's leading health agency activates emergency operations to better investigate the outbreak of lung injuries associated with e-cigarettes.

California will launch a $20 million ad campaign to warn against the dangers of vaping, Gov. Gavin Newsom announced Monday, the same day health officials said a 40-year-old had died over the weekend from complications related to using e-cigarettes.

Vaping-related illness recently killed another person in California, plus one person each in Kansas, Illinois, Indiana, Minnesota and Oregon, officials have reported.

In light of the outbreak of lung injuries, the US Centers for Disease Control has activated its Emergency Operations Center, the agency announced. Researchers are looking into 380 cases of lung illness associated with the use of e-cigarettes in 36 states and the US Virgin Islands, they have said.

California weighs steeper vaping pod taxes.

California, meantime, will focus on spreading the word about vaping risks while also boosting enforcement efforts on counterfeit products and weighing stricter package warning rules, Newsom said during a news conference.

The state also will investigate tax policy regarding vaping pods. A pack of cigarettes carries a tax of $2.87, while a Juul pod, for example, gets only a $1.48 tax, the governor said.

The intent of the investigation is to "substantially increase taxes to these products," said Newsom, who included the measures in an executive order he said is needed because of a lack of legislative efforts.

As for flavored e-cigarettes, "they should be banned," Newsom said, adding he could not add that parameter to his order, though he didn't explain why.

"Let's just dispense with any niceties," he said. "You don't have any bubblegum-flavored, mango-flavored tobacco products unless you're trying to target an audience that you were losing -- that's young people."

The Trump administration is working to ban flavored e-cigarettes as health officials warn they're too appealing to teens. Tobacco companies claim flavored e-cigarettes help adults quit traditional cigarettes.

'Serious potential risk associated with vaping'

The latest California victim had been sick for several weeks after he suffered a "severe pulmonary injury associated with vaping," Dr. Karen Haught, the Tulare County public health officer, said in a news release.

"The Tulare County Public Health Branch would like to warn all residents that any use of ecigarettes poses a possible risk to the health of the lungs and can potentially cause severe lung injury that may even lead to death," Haught said.

"Long-term effects of vaping on health are unknown. Anyone considering vaping should be aware of the serious potential risk associated with vaping," she said.

County of Los Angeles Public Health staff earlier this month announced the death of a resident potentially related to the use of e-cigarettes.

'It is time to stop vaping'

The first death identified as related to vaping was announced in August, when the Illinois Department of Public Health released a statement saying the person had been hospitalized with "severe respiratory illness" after recently vaping. Cases of vaping-related illness had been identified in 11 counties, the agency said.

A person in Oregon who had recently vaped products containing cannabis purchased at a dispensary died in July, according to a statement released in early September by the Oregon Health Authority.

The symptoms the patient suffered were similar to at least 200 cases in a national cluster that was mostly affecting teenagers and young adults, Oregon officials said.

"We don't yet know the exact cause of these illnesses -- whether they're caused by contaminants, ingredients in the liquid or something else, such as the device itself," said Dr. Ann Thomas, public health physician at OHA's Public Health Division.

Another death related to vaping was identified on September 6 by health officials in Indiana. The patient was older than 18 and died of a severe lung injury linked to a history of e-cigarette use.

The same day, the Minnesota of Department of Health said a patient who was over 65 had died in August after a long and complicated hospitalization. The patient had a history of underlying lung disease and suffered a severe lung injury associated with vaping THC products, Minnesota state epidemiologist, Dr. Ruth Lynfield, said in a news release.

Within a week, two more deaths were announced in Los Angeles County and Kansas.

The Kansas patient was over 50 and had a history of underlying health issues with symptoms that quickly progressed, the Kansas Department of Health and Environment said. What type of products the patient had used wasn't known, a news release stated.

"It is time to stop vaping," Kansas Department of Health and Environment Secretary Dr. Lee Norman said. "If you or a loved one is vaping, please stop.

The recent deaths across our country, combined with hundreds of reported lung injury cases continue to intensify."

CNN's Michael Nedelman, Jamie Gumbrecht, Cheri Mossburg

Video explains why inhaling a drug like nicotine is the fastest way to deliver it to the brain and also how cigarette companies and now vaping manufacturers have manipulated their products to make them even easier to lead to addiction.

The federal health agency reported 94 cases in 14 states and said the number is climbing.

By Mary Papenfuss

https://m.huffpost.com/us/entry/us_5d5b6ec4e4b0f667ed679101?utm_medium=facebook&utm_source=main_fb&ncid=fcbklnkushpmg00000063&utm_campaign=hp_fb_pages&guccounter=1

The federal Centers for Disease Control and Prevention is investigating the sudden emergence of severe lung disease linked to vaping in 14 states.

Ninety-four possible cases of severe lung illness associated with vaping were reported from the end of June to Aug. 15, the CDC reported on Saturday. Thirty of those cases were in Wisconsin alone. Other states that appear to be especially affected are Illinois, California, New York, Indiana and New Jersey. 

A survey of state health departments by CNN found at least 120 possible cases, the network reported Monday.

The largest number of cases, in Wisconsin, was first seen in teens and young adults, but the illness has now also appeared in older adults, according to a CDC statement.

Patients experience shortness of breath, coughing, fatigue, chest pain and weight loss. Symptoms worsen over time, and some patients need ventilators to breathe and intensive care. Some have been hospitalized for several weeks. The illness could be linked to permanent lung damage. All patients reported vaping in the weeks or months before hospitalization, said the CDC.

Investigators don’t yet know if only certain vaping brands are involved, or what specific ingredient had been consumed by those who were sickened. Products may include nicotine, THC, synthetic cannabinoids or some combination, the CDC reported. 

There is so far “no conclusive evidence that an infectious disease is causing the illnesses,” according to the health agency.

“While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses,” the CDC said in a brief statement.

“This is the headline we’ve been trying to prevent,” Joseph Allen, an environmental health scientist at Harvard University, told Popular Science. Allen is a co-author of a study published earlier this year that found fungi and bacteria in some popular brands of e-cigarette liquid. Allen also warned that flavors in vapes that may be safely ingested through the digestive tract aren’t tested for safety when aerosolized and inhaled.

“When you have millions of kids inhaling this cocktail of chemicals that were never tested for inhalation safety, this type of headline is predictable, and also avoidable,” Allen said. 

The CDC has sent notices and emails to physicians, hospitals and clinics providing background about the cases, and requests that they determine what vaping devices and brands people are using, what is being consumed — and to obtain samples if possible. The agency also asked whether people are sharing devices and ingredients. 

Earlier this month, the U.S. Food and Drug Administration said it had received more reports of e-cigarette users experiencing seizures and was investigating a possible link between vaping and neurological symptoms.

Dharma N. Bhatta and Stanton A. Glantz

Originally published 18 Jun 2019https://doi.org/10.1161/JAHA.119.012317Journal of the American Heart Association. 2019;8

https://www.ahajournals.org/doi/10.1161/JAHA.119.012317?fbclid=IwAR34_ZKD7TnpD9J5vCKXIzTL7MTYUivnjxJSRs0k-ZHddM9L0WSNtXRS7kQ&

Conclusions

Some‐day and every‐day e‐cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e‐cigarettes are similar as conventional cigarette and dual use of e‐cigarettes and conventional cigarettes at the same time is risker than using either product alone.

What Are the Clinical Implications?

E‐cigarettes should not be promoted or prescribed as a less risky alternative to combustible cigarettes and should not be recommended for smoking cessation among people with or at risk of myocardial infarction.

Abstract

Background

E‐cigarettes are popular for smoking cessation and as an alternative to combustible cigarettes. We assess the association between e‐cigarette use and having had a myocardial infarction (MI) and whether reverse causality can explain the observed cross‐sectional association between e‐cigarette use and MI.

Methods and Results

Cross‐sectional analysis of the Population Assessment of Tobacco and Health Wave 1 for association between e‐cigarette use and having had and MI. Longitudinal analysis of Population Assessment of Tobacco and Health Waves 1 and 2 for reverse causality analysis. Logistic regression was performed to determine the associations between e‐cigarette initiation and MI, adjusting for cigarette smoking, demographic and clinical variables. Every‐day (adjusted odds ratio, 2.25, 95% CI: 1.23–4.11) and some‐day (1.99, 95% CI: 1.11–3.58) e‐cigarette use were independently associated with increased odds of having had an MI with a significant dose‐response (P<0.0005). Odds ratio for daily dual use of both products was 6.64 compared with a never cigarette smoker who never used e‐cigarettes. Having had a myocardial infarction at Wave 1 did not predict e‐cigarette use at Wave 2 (P>0.62), suggesting that reverse causality cannot explain the cross‐sectional association between e‐cigarette use and MI observed at Wave 1.

Conclusions

Some‐day and every‐day e‐cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e‐cigarettes are similar as conventional cigarette and dual use of e‐cigarettes and conventional cigarettes at the same time is risker than using either product alone.

Clinical Perspective

What Is New?

Both e‐cigarettes and combustible cigarettes are independently associated with increased risk of myocardial infarction.

Dual use of e‐cigarettes and combustible cigarettes is riskier than using either product alone and switching from combustible cigarettes to e‐cigarettes is not associated with lower risk of myocardial infarction than continuing to smoke; complete cessation is the only way to reduce risk of myocardial infarction.

These results are unlikely becauseof reverse causality, where smokers who had myocardial infarctions started using e‐cigarettes in an effort to quit smoking.

What Are the Clinical Implications?

E‐cigarettes should not be promoted or prescribed as a less risky alternative to combustible cigarettes and should not be recommended for smoking cessation among people with or at risk of myocardial infarction.

Introduction

Cardiovascular disease is the leading cause of death in the United States1 and tobacco smoking is a major modifiable risk factor for cardiovascular disease, including myocardial infarction.2 The risk of myocardial infarction is 2‐ to 5‐fold higher among young smokers compared with never smokers,2, 3 with a non‐linear dose‐response curve with even the low levels of exposure associated with smoking a single cigarette a day4 or breathing secondhand smoke conferring substantial risk.5

E‐cigarettes are promoted as a smoking cessation device and less dangerous way to self‐administer nicotine than conventional cigarettes6, 7 and people with cardiovascular disease are using e‐cigarettes as a smoking cessation aid.8 Like conventional cigarettes, e‐cigarettes deliver nicotine as an inhaled aerosol of nicotine and ultrafine particles.9 Fine particles increase cardiovascular risk.10 E‐cigarettes and combustible cigarettes have similar effects on endothelial function which increases the risk of cardiovascular disease.11, 12, 13, 14, 15 E‐cigarettes increase oxidative stress and the release of inflammatory mediators,11, 16 induce platelet activation, aggregation, and adhesion17 and alters cardiovascular function in mice.18, 19, 20 Acute exposure to electronic cigarettes with nicotine increases aortic stiffness21 and cardiac sympathetic tone (reflected in heart rate variability) in a way associated with increased cardiac risk.13 Nevertheless, the 2018 National Academies of Science, Engineering, and Medicine report Public Health Consequences of E‐Cigarettes22 observed that “there are no epidemiological studies evaluating clinical outcomes such as coronary heart disease …. This lack of data on e‐cigarettes and clinical and subclinical atherosclerotic outcomes represents a major research need.” Since then, 2 studies, 1 using data from the National Health Interview Survey23 and another using data from the Behavioral Risk Factors Surveillance Survey,24 found cross‐sectional associations between e‐cigarette use and having had a myocardial infarction among daily e‐cigarette users controlling for cigarette smoking and other risk factors. Nevertheless, this finding remains controversial, because of concerns about reverse causality based on the possibility that after having a myocardial infarction smokers switched to e‐cigarettes, which would induce a spurious association between e‐cigarette use and myocardial infarction.25, 26 We use the Population Assessment of Tobacco and Health27 (PATH) data set to test for the relationship between e‐cigarette use and myocardial infarction, controlling for cigarette use, demographic and clinical variables and use the longitudinal data from PATH to test the reverse causality hypothesis.

Methods

Study Population and Design

We used PATH Waves 1 and 2 (Figure S1), a nationally representative population‐based longitudinal cohort study to collect data on uses of tobacco products, health outcomes, risk perception, and attitudes.27 The restricted use PATH data set is available at the University of Michigan National Addiction & HIV Data Archive Program.28 The Wave 1 data set contained 32 320 adults aged ≥18 years and 28 362 adults in Wave 2, of whom 26 447 completed a Wave 1 interview. Wave 1 data were collected from September 2013 to December 2014 and Wave 2 data were collected 1 year later (from October 2014 to October 2015). PATH uses a 4‐stage stratified probability sample technique. The weighted response rate at Wave 1 household screener was 54.0%; among screened households, overall weighted response rate at Wave 1 adult interview was 74.0%. The weighted retention rate for continuing adult at Wave 2 was 83.1%, and the weighted recruitment rate including youth aged <18 years at Wave 1 and ≥18 years (and so counted as adults at Wave 2) was 85.7%.28 Informed consent was obtained by PATH. The University of California San Francisco (UCSF) Committee on Human Research approved this study.

Outcome Variables

Wave 1: Participants who responded “Yes” to the question “Has a doctor, nurse, or other health professional ever told you that you had a heart attack (myocardial infarction)?” were considered as having had a myocardial infarction.

Wave 2: Participants who responded “Yes” to the question “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a heart attack (myocardial infarction)?” were considered as having had a myocardial infarction.

Independent Variables

Electronic cigarette use

Respondents who reported that they have ever used e‐cigarettes, have used fairly regularly, and currently use every day were classified as “Every‐day users.” Respondents who reported that they have ever used e‐cigarettes, have used fairly regularly, and currently use some days were considered as “Some‐day users.” Respondents who reported that they have ever used e‐cigarettes and currently do not use them were considered “Former users.” Respondents who reported that they have never used e‐cigarettes, even once or twice were considered “Never users.” Current experimental e‐cigarette users (current e‐cigarette users but never used e‐cigarettes fairly regularly) were not included in the main analysis but were considered some‐day users in a sensitivity analysis.

Cigarette smoking

Respondents who reported that they smoked at least 100 cigarettes in their lifetime and currently smoke every day were classified as “Every‐day smokers.” Respondents who reported that they smoked at least 100 cigarettes in their lifetime and currently smoke some days were classified as “Some‐day smokers.” Respondents who ever smoked cigarettes and have not smoked in the past 12 months or currently do not smoke at all were classified as “Former smokers.” Respondents who reported that they have never smoked a cigarette, even 1 or 2 puffs were classified as “Never smokers.” Respondents who were current smokers but who had not smoked 100 cigarettes (experimental smokers) were excluded from the main analysis, but included in a sensitivity analysis as some‐day smokers.

Demographic variables

Demographic variables were assessed at Wave 1: age, body mass index (BMI), sex (men or women), race/ethnicity (white, black, Asian, and others), poverty level/income (below poverty: <100% of poverty line, at or above poverty: ≥100% of poverty line [poverty was calculated using this formula: [effective family income]/[poverty guideline]×100=family income as a percentage of the household size poverty guideline.]) and education.

Clinical variables

Wave 1: Respondents who answered “Yes” to the question “Has a doctor, nurse, or other health professional ever told you that you had a high blood pressure?” were considered as having “high blood pressure.” Respondents who answered “Yes” to the question “Has a doctor, nurse or other health professional ever told you that you had a high cholesterol?” were considered as having “high cholesterol.” Respondents who answered “Yes” to the question “Has a doctor, nurse, or other health professional ever told you that you had a diabetes, sugar diabetes, high blood sugar, or borderline diabetes?” were considered as having “diabetes mellitus.”

Wave 2: Respondents who answered “Yes” to the question “In the past 12 months, has a doctor, nurse or other health professional told you that you had a high blood pressure?” were considered as having “high blood pressure.” Respondents who answered “Yes” to the question “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a high cholesterol?” were considered as having “high cholesterol”. Respondents who answered “Yes” to the question “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a diabetes, sugar diabetes, high blood sugar, or borderline diabetes?” were considered as having “diabetes mellitus.”

Analysis

We calculated weighted estimates of e‐cigarette and cigarette use and clinical and demographic variables at Wave 1 for the overall sample. We used Wave 1 sampling weights for analysis of Wave 1 and Wave 2 sampling weights for analysis of Wave 228 accounting for the complex survey design for all the outcomes.29

Multivariable logistic regressions were performed to examine the associations between e‐cigarette use (former, some day and every day) and myocardial infarction at Wave 1 controlling for cigarette smoking (former, some day and every day), age, BMI, sex, poverty level, race/ethnicity, education, and clinical variables.

We tested for interaction between e‐cigarette use and cigarette smoking in a logistic regression by combining some‐day and every‐day users into “current e‐cigarette use” and “current smoking,” then ran the logistic regression with these variables, their interaction, and the demographic and clinical variables. The P value for the interaction was 0.671. Likewise, we analyzed interaction for “former e‐cigarette use” and “former smoking”, and P value for this model was 0.192. As a result, interaction terms were omitted from the remaining analysis.

We tested for dose‐response by replacing the categorical use variables with continuous variables (0=never, 1=former, 2=some day, 3=every day) in logistic regressions including the demographic and clinical variables.

We assessed the possibility of reverse causality accounting for the observed association between having had a myocardial infarction at Wave 1 being due to people who had a myocardial infarction preferentially trying to quit smoking with e‐cigarettes. Specifically, we used logistic regression to predict every day e‐cigarette use at Wave 2 as a function of having had a myocardial infarction at Wave 1 adjusting for age, BMI, sex, poverty level, and race/ethnicity among only every day, and only current (every day and some day) cigarette smoker at Wave 1 (excluding all e‐cigarette users) as well as in the entire longitudinal sample.

We used “survey package” in R software for statistical analyses.

Results

Table 1 shows the descriptive statistics at Wave 1 baseline; 643 (2.4%) adults reported that they had a myocardial infarction. Table 2 shows the descriptive statistics stratified by myocardial infarction status at Wave 1 and first myocardial infarctions between Waves 1, 2, and 3 and Table S1 shows the descriptive statistics stratified by e‐cigarette use at Wave 1. Among the adults who had myocardial infarctions as of Wave 1, 10.2% reported that they were former e‐cigarette users, 1.6% were some‐day e‐cigarette users and 1.5% were every‐day e‐cigarette users, 58.8% adults reported that they were former cigarette smokers, 3.4% were some‐day cigarette smokers and 20.4% were every‐day cigarette smokers. The number of e‐cigarette users who had first myocardial infarctions between Waves 1 and 2 (only 6 some‐day and 2 every‐day e‐cigarette users) and Waves 2 and 3 (only 1 some‐day and 3 every‐day e‐cigarette users) was small, so, as required by PATH reporting rules, we combined some‐day and every‐day e‐cigarette users in Table 2 for the first myocardial infarction between Waves 1 and 2, and Waves 2 and 3.

As expected, any cigarette smoking, age, BMI, sex, poverty level, education, and high blood pressure, high cholesterol, and diabetes mellitus were significantly associated with increased risk of myocardial infarction.

There was a significant dose‐response for both e‐cigarette use (P<0.0005) and smoking (P=0.019) and myocardial infarction controlling for demographic and clinical variables (detailed results not shown).

The longitudinal analysis did not reveal any statistically significant associations between e‐cigarette use at Wave 1 and having had a first myocardial infarction by Wave 2, perhaps because of the small numbers of first myocardial infarctions in e‐cigarette users between Waves 1 and 2 (Table S2). Daily cigarette smoking was also not significantly associated with having had a first myocardial infarction at Wave 2.

The sensitivity analysis including current experimental e‐cigarette user with some‐day e‐cigarette user and current experimental cigarette smokers with some‐day cigarette smokers yielded similar results as the main analysis (Table S3).

Reverse Causality

There were 1990 respondents who started using e‐cigarettes between Waves 1 and 2 (Table 4). Having had a myocardial infarction at Wave 1 did not predict every‐day e‐cigarette use at Wave 2 among overall follow‐up sample (P=0.687), every‐day cigarette smokers at Wave 1 (P=0.675), or current cigarette smokers at Wave 1 (P=0.634), adjusting for demographic and clinical variables. Similar results were obtained for any e‐cigarette use (every day or some day) at Wave 2 (Table S4).

Click here to see tables

Discussion

This study confirms earlier23, 24 findings that e‐cigarette use is an independent risk factor for having had a myocardial infarction controlling for cigarette smoking, demographic and clinical risk factors. The magnitudes of the effects in this study are similar to the updated analysis by Alzahrani and Glantz30 using the 2014, 2015, and 2016 from the National Health Interview Survey (some‐day e‐cigarette user [odds ratio: 1.99, 95% CI: 1.11–3.58 in this study versus 1.49: 1.08–2.09 in Alzahrani et al] and every‐day e‐cigarette user [2.25: 1.23–4.11 versus 2.14: 1.41–3.25]). Odds of myocardial infarction among former e‐cigarette users are not significantly elevated in either study. The increased odds of myocardial infarction are similarly and significantly associated with smoking in both studies, with higher estimates in the present study (former [1.48: 1.01–2.15 versus 1.70: 1.51–1.91], some day [2.38: 1.40–4.06 versus 2.36; 1.80–3.09] and every day [2.95: 1.91–4.56 versus 2.72: 2.29–3.24]). Vindhyal et al31 reported that e‐cigarette use is significantly associated with MI (odds ratio [OR] 1.56 [1.45–1.68]), stroke (OR 1.30 [1.20–1.40]), and circulatory problems (OR 1.44 [1.25–1.65]) using the 2014, 2016, and 2017 National Health Interview Survey. Ndunda and Muutu24 found that compared with non‐users, e‐cigarette users (without specifying frequency of use, but controlling for smoking and other risk factors) the odds of having had a myocardial infarction (OR 1.59 [1.53–1.66]) that was lower than in this study, although the CIs overlapped. They also found higher risks for angina or coronary heart disease (OR 1.4 [1.35–1.46]) and stroke (OR 1.71 [1.64–1.8]) using 2016 Behavioral Risk Factor Surveillance System.

Both the present and earlier23, 24 results are based on cross‐sectional analysis, which raises the possibility of reverse causality,25, 26 specifically that after having had a myocardial infarction people might preferentially attempt to quit smoking using e‐cigarettes. In a cross‐sectional analysis of the National Health Interview Survey, Stokes et al8 reported that individuals with cardiovascular disease who recently quit smoking or recently attempt to quit were more likely to use e‐cigarettes than those who did not report a recent quit attempt, which may indicate that e‐cigarettes were being used for smoking cessation. We used the longitudinal data in PATH to test directly for reverse causality by testing whether having had a myocardial infarction at Wave 1 predicted e‐cigarette use at Wave 2 among people who were cigarette smokers at Wave 1 (Table 4). The results did not approach statistical significance (P>0.62 for all outcomes), strongly suggesting that reverse causality is not an issue. In addition, the presence of a statistically significant dose‐response is consistent with a causal effect.

Our results on the lack of reverse causality are consistent with Gaalema et al32 who concluded based on longitudinal analysis of the first 2 waves of PATH, that having a myocardial infarction was not a significant predictor of initiating non‐combusted tobacco (mostly e‐cigarettes) use (P=0.20). Furthermore, they found, “cardiac status was significantly negatively associated with switching completely from combusted to non‐combusted products. While 9.2% of those with no change in health status switched (from combusted tobacco, mostly cigarettes) to non‐combusted use, none of those experiencing a new MI switched (P=0.0015).” Thus, any differential misclassification is in the direction opposite to what would be required for reverse causality to explain our results, which strengthens our conclusion that e‐cigarette use is associated with the risk of having had an MI. Our finding is also consistent with Alzahrani et al's26 cross‐sectional analysis of reverse causality using the National Health Interview Survey, which found a non‐significant association between MI and e‐cigarette use when controlling for covariates.

Like Alzahrani et al,23, 30 we found that the increased odds of having had a myocardial infarction associated with e‐cigarette use were independent of the increased odds associated with smoking. This result means that dual use of e‐cigarettes and conventional cigarettes, the most common use pattern for e‐cigarette users, is more dangerous than use of either product alone (69% of current e‐cigarette users were also smoking cigarettes in our sample at Wave 1, which is similar to the 70% Stokes et al8 reported among people with cardiovascular disease in the National Health Interview Survey). For example, the total odds of having had a myocardial infarction among every‐day cigarette smokers who also use e‐cigarettes every day (dual users)—the most common use pattern (Table 1)—is (odds of myocardial infarction among every‐day smokers)×(odds of myocardial infarction among every‐day e‐cigarette user)=2.95×2.25=6.64 compared with a never cigarette smoker who has never used e‐cigarettes (which is similar from additional regression analysis estimating the effect directly, Adjusted Odds Ratio (AOR): 5.06, 95% CI: 1.99–12.83, Table S5). Odds of having had a myocardial infarction for individuals who switched from every‐day combustible cigarette smoking to every‐day e‐cigarette use would change by a factor of ([odds of myocardial infarction among former combustible cigarette smokers]×[odds of myocardial infarction among every‐day e‐cigarette user])/(odds of myocardial infarction among every‐day combustible cigarette smoker)=3.33/2.95=1.13, which is virtually no benefit in terms of myocardial infarction risk. More importantly, the total odds of having had a myocardial infarction for an individual who switched from every‐day combustible cigarette smoking to every‐day e‐cigarette use compared with quitting smoking would be ([odds of myocardial infarction among former smokers]×[odds of myocardial infarction among every‐day e‐cigarette user])/(odds of myocardial infarction among former cigarette smokers)=(1.48×2.25)/1.48=2.25.

As discussed above, we cannot infer temporality from the cross‐sectional finding that e‐cigarette use is associated with having had an MI and it is possible that first MIs occurred before e‐cigarette use. PATH Wave 1 was conducted in 2013 to 2014, only a few years after e‐cigarettes started gaining popularity on the US market around 2007. To address this problem we used the PATH questions “How old were you when you were first told you had a heart attack (also called a myocardial infarction) or needed bypass surgery?” and the age when respondents started using e‐cigarettes and cigarettes (1) for the very first time, (2) fairly regularly, and (3) every day. We used current age and age of first MI to select only those people who had their first MIs at or after 2007 (Table S6). While the point estimates for the e‐cigarette effects (as well as other variables) remained about the same as for the entire sample, these estimates were no longer statistically significant because of a small number of MIs among e‐cigarette users after 2007. Note that this analysis does not capture reinfarctions occurring after 2007, whose risk could be increased by e‐cigarette use as it is for continued smoking conventional cigarettes.33, 34

One could argue that the cleanest study would have been one that only examined the association of sole e‐cigarette use with myocardial infarction. In contrast, most e‐cigarette users are dual users with cigarettes so it is important to study the effects of e‐cigarette use simultaneously with cigarette use. Our analysis quantified the additional risk of MI associated with e‐cigarette use in addition to cigarette smoking among dual users. Limiting the analysis to sole e‐cigarette users would not only be less clinically relevant, but would substantially reduce the sample size and the power of the analysis to detect an effect.

Limitations

While PATH is a longitudinal study, there were only 8 people who used e‐cigarettes and had first myocardial infarctions during this follow‐up, so there was not enough power to detect an effect. Confirming this problem, every‐day and former‐conventional cigarette smoking were not significant either. While longitudinal studies are more desirable than cross‐sectional studies, the reality is that it will be years before enough myocardial infarctions have occurred to do a meaningful analysis. In the meantime, millions of people are using e‐cigarettes and clinicians are being asked about them and this cross‐sectional analysis can be used to inform decision making about these products.

Response for both e‐cigarette and combustible cigarette use were self‐reported, which could lead to recall bias. Participants with myocardial infarction might over‐report e‐cigarette and cigarette use, but previous work found that compared with biochemical monitoring with cotinine levels, self‐reporting in myocardial infarction survivors tended to understate the prevalence of smoking.35 Myocardial infarction was self‐reported which also could lead recall bias, but the questions “Has a doctor, nurse, or other health professional ever told you that you had a heart attack (myocardial infarction)?” and “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a heart attack (myocardial infarction)?” have been found to have high agreement (81%–98%) with medical records.36, 37

Other possible risk factors including family history of myocardial infarction, angina, and heavy alcohol use are not available in the PATH data set. There is no information on the duration since smoking or e‐cigarette cessation. In the main analysis, it also is unknown whether the reported myocardial infarction occurred before or after the respondents’ initiated e‐cigarettes and cigarettes use.

Conclusions

As one would expect based on what is known about the biological effects of e‐cigarette use, in the cross‐sectional analysis some‐day and every‐day e‐cigarette use is associated with increased risk for having myocardial infarction, adjusted for combustible cigarette smoking, demographic and clinical variables. This result is unlikely because of reverse causality. Former, some‐day, and every‐day combustible cigarette smoking is also independently associated with myocardial infarction among adults in the United States. Dual use of the e‐cigarette and combustible cigarettes results in higher risk of myocardial infarction than using either product alone and switching from cigarettes to e‐cigarettes was not associated with any benefits in terms of reduced myocardial infarction risk. E‐cigarettes should not be promoted or prescribed as a less risky alternative to combustible cigarettes and should not be recommended for smoking cessation among people with or at risk of myocardial infarction.

Sources of Funding

This work was supported by grants R01DA043950 from the National Institute on Drug Abuse, P50CA180890 from the National Cancer Institute and the Food and Drug Administration Center for Tobacco Products, U54HL147127 from the National Heart, Lung, and Blood Institute and the Food and Drug Administration Center for Tobacco Products, and the University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center Global Cancer Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institutes of Health or the Food and Drug Administration. The funding agencies played no role in study design, collection, analysis, and interpretation of data, writing the report, or the decision to submit for publication.

Disclosures

None.

Footnotes

*Correspondence to: Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education, University of California, San Francisco, 530 Parnassus Ave, Suite 366, San Francisco, CA 94143‐1390. E‐mail: stanton.glantz@ucsf.edu

Stanton A. Glantz, PhD1

The Evidence of Electronic Cigarette Risks Is Catching Up With Public Perception

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The advent of electronic cigarettes (e-cigarettes), devices that deliver a nicotine aerosol to the lungs by heating a nicotine-containing liquid rather than burning tobacco, has triggered an intense debate over their value for reducing the harm tobacco products cause. The optimists see e-cigarettes delivering nicotine without all the combustion byproducts of conventional cigarettes,1 whereas others point out that e-cigarettes still deliver an aerosol of ultrafine particles and other toxicants that carry substantial health risks.2

A key to realizing the optimists’ vision for e-cigarettes is smokers switching completely from cigarettes to e-cigarettes. Because perceived risks play an important role in selecting tobacco products, Huang and colleagues3 examined how perceptions of the risk of e-cigarettes compared with cigarettes have changed from 2012 to 2017 using 2 national surveys, the Tobacco Products and Risk Perceptions Surveys they conducted and the Health Information National Trends Surveys (HINTS). They found that the fraction of respondents who believed that e-cigarettes were less harmful than cigarettes decreased from approximately 45% in 2012 to approximately 35% in 2017, whereas the fraction who thought they were about the same increased to approximately 45%. (These estimates combine the 2 surveys. The estimates of “about the same” in 2012 were very different in the 2 surveys, so are not listed here; the other results were more similar.) The fractions who thought e-cigarettes were more dangerous than cigarettes increased but remained low, at less than 10%.

Huang and colleagues3 express concern that as fewer people view e-cigarettes as less harmful than cigarettes, fewer will be interested in switching from combustible cigarettes to e-cigarettes. Based on the evidence available in 2017, the National Academies of Science, Engineering, and Medicine concluded that “e-cigarettes pose less risk to an individual than combustible tobacco cigarettes.”4(p11) The report emphasized that at the time, no studies on the long-term health effects of e-cigarettes had been performed, which they recognized as a limitation. However, the data are catching up with public perception.

Since the report was completed, evidence has started to emerge that e-cigarette users are at increased risk of myocardial infarction,5-7 stroke,6 and chronic obstructive pulmonary disease and other respiratory diseases,8-10 controlling for smoking and other demographic and risk factors. Some of these risks approach those of smoking cigarettes. There is also emerging evidence that e-cigarettes deregulate biologically significant genes associated with cancer.11 Equally important, the risks of e-cigarette use are in addition to any risks of cigarette smoking, which means that dual users (people who continue to smoke cigarettes while using e-cigarettes) have higher risks of heart and lung disease than people who just smoke. This finding is particularly important because, contrary to the hopes of the e-cigarette optimists, about two-thirds of adult e-cigarette users are dual users (ie, continue to smoke).

In addition, although 1 randomized clinical trial12 has shown that e-cigarettes improve cessation when used as part of a clinically supervised smoking cessation program that includes intensive counseling, as used in the population as a whole as a mass-marketed consumer product, e-cigarettes are associated with reduced odds of cessation.13 In addition, 80% of former cigarette smokers were continuing to use e-cigarettes 6 month later. Although not a direct health effect (in the same way that exposure to e-cigarette aerosol triggers pathophysiological processes that increase the risk of heart and lung disease), this effect of depressing smoking cessation in the population as a whole is another risk of using e-cigarettes.

Increased perceived risks of e-cigarettes is also an important element for curbing their use by youth. Youth who believe that e-cigarettes are not harmful or are less harmful than cigarettes are more likely to use e-cigarettes than youth with more negative views of e-cigarettes.14 In terms of overall public health effects, this explosion of youth use swamps any potential harm reduction that may accompany adults switching from cigarettes to e-cigarettes.15 From this perspective, the declining public perception that e-cigarettes are less harmful than cigarettes is a good thing that may turn out to be where the scientific consensus lands as the new evidence on the harms of e-cigarettes continues to accumulate.

References

1.  Abrams  DB, Glasser  AM, Pearson  JL, Villanti  AC, Collins  LK, Niaura  RS.  Harm minimization and tobacco control: reframing societal views of nicotine use to rapidly save lives.  Annu Rev Public Health. 2018;39(1):193-213. doi:10.1146/annurev-publhealth-040617-013849PubMedGoogle ScholarCrossref

2.  Glantz  SA, Bareham  DW.  E-cigarettes: use, effects on smoking, risks, and policy implications.  Annu Rev Public Health. 2018;39:215-235. doi:10.1146/annurev-publhealth-040617-013757PubMedGoogle ScholarCrossref

3.  Huang  J, Feng  B, Weaver  SR, Pechacek  TF, Slovic  P, Eriksen  MP.  Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US national surveys from 2012 to 2017.  JAMA Netw Open. 2019;2(3):e191047. doi:10.1001/jamanetworkopen.2019.1047ArticleGoogle Scholar

4.  National Academies of Sciences, Engineering, and Medicine.  Public Health Consequences of e-Cigarettes. Washington, DC: National Academies Press; 2018. doi:10.17226/24952

5.  Alzahrani  T, Pena  I, Temesgen  N, Glantz  SA.  Association between electronic cigarette use and myocardial infarction.  Am J Prev Med. 2018;55(4):455-461. doi:10.1016/j.amepre.2018.05.004PubMedGoogle ScholarCrossref

6.  Ndunda  PM, Muutu  TM. Electronic cigarette use is associated with a higher risk of stroke. International Stroke Conference 2019 Oral Abstracts. Stroke. 2019;50(suppl 1):abstract 9. https://www.ahajournals.org/doi/10.1161/str.50.suppl_1.9. Accessed February 8, 2019. 

7.  Bhatta  D, Glantz  SA. Electronic cigarette use and myocardial infarction among adults in the United States Population Assessment of Tobacco and Health. Paper presented at: Society for Research on Nicotine and Tobacco Annual Meeting; February 20-23, 2019; San Francisco, CA. Abstract P0S4-99. https://cdn.ymaws.com/www.srnt.org/resource/resmgr/SRNT19_Abstracts.pdf. Accessed February 26, 2019. 

8.  Perez  M, Atuegwu  N, Mead  E, Oncken  C, Mortensen  E. E-cigarette use is associated with emphysema, chronic bronchitis and COPD (A6245). American Thoracic Society Session D22: Cutting Edge Research in Smoking Cessation and E-cigarettes. http://www.abstractsonline.com/pp8/#!/4499/presentation/19432. Published May 23, 2018. Accessed February 9, 2019. 

9.  Wills  TA, Pagano  I, Williams  RJ, Tam  EK.  E-cigarette use and respiratory disorder in an adult sample.  Drug Alcohol Depend. 2019;194:363-370. doi:10.1016/j.drugalcdep.2018.10.004PubMedGoogle ScholarCrossref

10.  Bhatta  D, Glantz  SA. Electronic cigarette use is associated with respiratory disease among adults in the United States Population Assessment of Tobacco and Health: a longitudinal analysis. Paper presented at: Society for Research on Nicotine and Tobacco Annual Meeting; February 22-23, 2019; San Francisco, CA. Abstract P0S2-146. https://cdn.ymaws.com/www.srnt.org/resource/resmgr/SRNT19_Abstracts.pdf. Accessed February 26, 2019. 

11.  Tommasi  S, Caliri  AW, Caceres  A,  et al.  Deregulation of biologically significant genes and associated molecular pathways in the oral epithelium of electronic cigarette users.  Int J Mol Sci. 2019;20(3):738. doi:10.3390/ijms20030738PubMedGoogle ScholarCrossref

12.  Hajek  P, Phillips-Waller  A, Przulj  D,  et al.  A randomized trial of e-cigarettes versus nicotine-replacement therapy.  N Engl J Med. 2019;380(7):629-637. doi:10.1056/NEJMoa1808779PubMedGoogle Scholar

13.  Kalkhoran  S, Glantz  SA.  E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis.  Lancet Respir Med. 2016;4(2):116-128. doi:10.1016/S2213-2600(15)00521-4PubMedGoogle ScholarCrossref

14.  Gorukanti  A, Delucchi  K, Ling  P, Fisher-Travis  R, Halpern-Felsher  B.  Adolescents’ attitudes towards e-cigarette ingredients, safety, addictive properties, social norms, and regulation.  Prev Med. 2017;94:65-71. doi:10.1016/j.ypmed.2016.10.019PubMedGoogle ScholarCrossref

15.  Soneji  SS, Sung  HY, Primack  BA, Pierce  JP, Sargent  JD.  Quantifying population-level health benefits and harms of e-cigarette use in the United States.  PLoS One. 2018;13(3):e0193328. doi:10.1371/journal.pone.0193328PubMedGoogle ScholarCrossref

Many people are being told and often truly believe that using electronic cigarettes or other vaping products is safe or nearly harmless. This video and its associated resource page explains why so many people believe this statement and how they are wrong.

Resources referred to in this video:

Professor Simon Chapman’s blog referred to in this video

Critical review of Public Health England’s view that vaping is 95% safer than smoking

Other related resources:

Vaping: What you can’t see can still hurt you

STUDENT ALERT: e-cigarettes and juuling are dangerous

We ignored the evidence linking cigarettes to cancer. Let's not do that with vaping

Premature deaths caused by smoking

A conflict of interest is strongly associated with tobacco industry-favourable results, indicating no harm of e-cigarettes.

Our views on the need for harm reduction

Resources regarding the use of electronic cigarettes as a quitting aid

Parent to parent e-cigarette, Juul and nicotine addiction warnings

Kids and vaping: an ounce of prevention is worth a pound of cure

Katie Byrne

March 6 2019 2:30 AM

https://www.independent.ie/life/health-wellbeing/katie-byrne-on-vaping-in-a-matter-of-months-my-ecigarette-became-more-like-a-childs-pacifier-37881250.html?fbclid=IwAR1id2gXzi1GnMIWBbGkcxqtcV3zejcbCCC8MRG3uUZ3e7uw9ZaqEdTXFO4

It's National No Smoking Day today, but as someone who has a chronic nicotine addiction, I'm not entirely sure if I should be celebrating it.

Granted, I don't habitually smoke cigarettes anymore and that's an achievement in anyone's language. But I'm still addicted to nicotine. In fact, I worry that I might be more addicted to it than ever before.

Like a lot of smokers, I swapped cigarettes for e-cigarettes a few years ago. Vaping gives ex-smokers the familiar white plumes of smoke (or rather vapor), the satisfying throat hit (don't judge - I'm an addict) and the habitual hand-to-mouth action. In other words, it's pretty easy to make the transition - or at least, as easy as it gets.

The trouble is that it's almost too easy. Those who might only have smoked outdoors can now vape indoors; those who once worried about the musty smell of tobacco on their clothes need now only worry about the syrupy scents of cola, vanilla and bubblegum.

For someone who is addicted to nicotine, the convenience factor can be the difference between smoking a cigarette every few hours and vaping every few minutes.

In a matter of months, my e-cigarette became more like a child's pacifier. Save for the times when it was charging, it was never far from my hands. I vaped while I worked. I vaped while I cooked. I vaped while I vaped.

And I wasn't alone. I know dozens of people whose vaping habits have become compulsive; people who thought e-cigarettes could help them wean off nicotine but who actually ended up consuming more of the chemical than ever before.

I eventually swapped vaping for nicotine spray after a friend remarked that I needed my e-cigarette like an astronaut needs their oxygen tank. And while it feels good to be free from the finicky paraphernalia of coils and wicks and whatnot, the truth is that I've simply found another long-term nicotine replacement.

There is no doubt that vaping and other forms of nicotine replacement therapy (NRT) have helped millions of people to quit smoking but it's important that we see through the smokescreen and recognise that these companies aren't always focused on freeing people from nicotine dependence.

Good vape shops, for example, will help new customers to devise a programme that allows them to gradually reduce their nicotine intake and, with it, their vaping habit. The problem, of course, is that the vast majority of these businesses are too busy trying to reposition the vaping habit as a casual "hobby".

The global smoking cessation market is expected to reach over $22bn by 2024. When you consider these eye-watering figures, you begin to understand that nicotine products like gums, lozenges, e-cigarettes and so-forth are being used as long-term lifestyle drugs rather than temporary quit aids.

Again, it's a much better proposition than being addicted to cancer-causing cigarettes, but it's still a form of addiction and addiction is still a drag (even when it has a fresh minty flavour).

On National No Smoking Day, we hear about the thousands of people who successfully quit the habit (80,000 Irish people have given up smoking over the past three years, according to a recent Healthy Ireland survey) but we hear nothing about the people who are still addicted to nicotine-based products. Nor do we hear about the emerging health threat of teenage nicotine addiction

The FDA recently described the use of e-cigarettes among young people as an "epidemic". What's interesting is that this generation never smoked cigarettes. What's more, they are addicted to new generation, nicotine salt-based e-cigarettes like Juul, which deliver a smoother and faster throat hit.

Ireland aims to be completely tobacco-free by 2025, and while that's a target that we can all get behind, we should be careful not to trivialise the issue of nicotine dependence in the process. More than that, we should understand the true success rates of NRT - that is the numbers of people who successfully quit all nicotine products after using them - before we recommend them to quitters.

After years of using nicotine-replacement products, I'm beginning to realise that only good old fashioned cold turkey is going to help me overcome nicotine dependence, just as I'm beginning to wonder if I've been delaying the inevitable all along.

Data reveal toll of vaping; researchers say switching to e-cigarettes doesn't eliminate health risks

Date:  March 7, 2019

Source:  American College of Cardiology

Summary:  Concerns about the addictive nature of e-cigarettes -- now used by an estimated 1 out of 20 Americans -- may only be part of the evolving public health story surrounding their use, according to new data. New research shows that adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don't use them or any tobacco products.

https://www.sciencedaily.com/releases/2019/03/190307103111.htm?fbclid=IwAR1NaJHW2AC6fQ8duo1sOIk6Dhh_Ysedp_5_JjtE8k7JlLzxzqXZB289ZLw

Concerns about the addictive nature of e-cigarettes -- now used by an estimated 1 out of 20 Americans -- may only be part of the evolving public health story surrounding their use, according to data being presented at the American College of Cardiology's 68th Annual Scientific Session. New research shows that adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don't use them or any tobacco products.

"Until now, little has been known about cardiovascular events relative to e-cigarette use. These data are a real wake-up call and should prompt more action and awareness about the dangers of e-cigarettes," said Mohinder Vindhyal, MD, assistant professor at the University of Kansas School of Medicine Wichita and the study's lead author.

E-cigarettes -- sometimes called "e-cigs," "vapes," "e-hookahs," "vape pens" or "electronic nicotine delivery systems" -- are battery-operated, handheld devices that mimic the experience of smoking a cigarette. They work by heating the e-liquid, which may contain a combination of nicotine, solvent carriers (glycerol, propylene and/or ethylene glycol) and any number of flavors and other chemicals, to a high enough temperature to create an aerosol, or "vapor," that is inhaled and exhaled. According to Vindhyal, there are now more than 460 brands of e-cigarettes and over 7,700 flavors.

E-cigarettes have been gaining in popularity since being introduced in 2007, with sales increasing nearly 14-fold in the last decade, researchers said. But they are also hotly debated -- touted by some as a safer alternative to smoking tobacco, while others are sounding the alarm about the explosion of vaping among teens and young adults.

This study found that compared with nonusers, e-cigarette users were 56 percent more likely to have a heart attack and 30 percent more likely to suffer a stroke. Coronary artery disease and circulatory problems, including blood clots, were also much higher among those who vape -- 10 percent and 44 percent higher, respectively. This group was also twice as likely to suffer from depression, anxiety and other emotional problems.

Most, but not all, of these associations held true when controlling for other known cardiovascular risk factors, such as age, sex, body mass index, high cholesterol, high blood pressure and smoking. After adjusting for these variables, e-cigarette users were 34 percent more likely to have a heart attack, 25 percent more likely to have coronary artery disease and 55 percent more likely to suffer from depression or anxiety. Stroke, high blood pressure and circulatory problems were no longer statistically different between the two groups.

"When the risk of heart attack increases by as much as 55 percent among e-cigarettes users compared to nonsmokers, I wouldn't want any of my patients nor my family members to vape. When we dug deeper, we found that regardless of how frequently someone uses e-cigarettes, daily or just on some days, they are still more likely to have a heart attack or coronary artery disease," Vindhyal said.

The study, one of the largest to date looking at the relationship between e-cigarette use and cardiovascular and other health outcomes and among the first to establish an association, included data from a total of 96,467 respondents from the National Health Interview Survey, a Centers for Disease Control and Prevention-fielded survey of Americans, from 2014, 2016 and 2017. The 2015 survey did not include any e-cigarette-related questions. In their analyses, researchers looked at the rates of high blood pressure, heart attack, stroke, coronary artery disease, diabetes and depression/anxiety among those who reported using e-cigarettes (either some days or daily) and nonusers. Those who reported using e-cigarettes were younger than nonusers (33 years of age on average vs. 40.4 years old).

Researchers also compared the data for reported tobacco smokers and nonsmokers. Traditional tobacco cigarette smokers had strikingly higher odds of having a heart attack, coronary artery disease and stroke compared with nonsmokers -- a 165, 94 and 78 percent increase, respectively. They were also significantly more likely to have high blood pressure, diabetes, circulatory problems, and depression or anxiety.

The researchers also looked at health outcomes by how often someone reported using e-cigarettes, either "daily" or "some days." When compared to non-e-cigarette users, daily e-cigarette users had higher odds of heart attack, coronary artery disease and depression/anxiety, whereas some days users were more likely to have a heart attack and suffer from depression/anxiety, with only a trend toward coronary artery disease. Researchers said this could be due to decreased toxic effects of e-cigarette usage, early dissipation of the toxic effects, or the fact that it has not been studied long enough to show permanent damage to portray cardiovascular disease morbidity.

"Cigarette smoking carries a much higher probability of heart attack and stroke than e-cigarettes, but that doesn't mean that vaping is safe," Vindhyal said, adding that some e-cigarettes contain nicotine and release very similar toxic compounds to tobacco smoking. Nicotine can quicken heart rate and raise blood pressure.

There are some limitations. For example, the study design doesn't allow researchers to establish causation, but Vindhyal said it does show a clear association between any kind of smoking and negative health outcomes. He added that self-reported data is also subject to recall bias. The researchers were also unable to determine whether these outcomes may have occurred prior to using e-cigarettes. Further longitudinal data is needed.

Story Source:  Materials provided by American College of Cardiology. Note: Content may be edited for style and length.

Stanton A. Glantz, PhD

https://tobacco.ucsf.edu/e-cig-use-among-kids-doubles-england-enthusiasts-still-trying-ignore-it?fbclid=IwAR0-SzVIKc_Un6QLkvaosKHV1mhOtSBKoL0DV5oVk1UMgJ1EwcDybBaN4iM

E-cig use among kids doubles in England ; enthusiasts still trying to ignore it

After years of arguing that people didn’t need to worry about increasing e-cig use among kids in England, because of the different (from the USA) regulatory environment, e-cig cheerleading Public Health England announced e-cig use among kids doubled in the last 4 years.  And that was before Juul invaded.

As expected, the Public Health England (a government agency) minimized the effect, as did, ASH England and other e-cig enthusiasts minimized this huge increase on the grounds that few kids were “regular” e-cig users.  This argument ignores the fact that the evidence (collected by e-cig enthusiasts!) shows that among kids who use tobacco in England, more than half are initiating nicotine use with e-cigs and any e-cig use predicts future smoking.  Indeed, the “gateway” effect in England is about 12, compared to 3-4 in the USA. 

And even if the kids did not add cigarettes later, bathing developing brains in nicotine is a very bad thing because the neurological changes are permanent. 

This argument that “experimentation” with cigarettes among kids is not important is something that the tobacco industry has used for a long time to try and minimize youth smoking.  Lauren Dutra and I showed that any cigarette smoking among young teens predicts smoking in their 20’s.

At least the media is figuring out that this is a problem.  Here is some of the coverage:

https://www.thesun.co.uk/news/8516445/number-of-under-18s-using-e-cigarettes-doubles-in-four-years-figures-show/

https://www.telegraph.co.uk/news/2019/02/27/number-children-vaping-doubles-five-years-new-research-shows/

https://www.dailymail.co.uk/health/article-6747813/amp/Number-children-young-people-vaping-DOUBLES-four-years.html?__twitter_impression=true

We ignored the evidence linking cigarettes to cancer. Let's not do that with vaping

Since 2011, e-cigarettes and vaping has increased in teens since 2011, and we still don’t know the long-term health effects

Today, it seems so obvious. Cigarettes and tobacco cause lung cancer. It is remarkable however, that this relationship wasn’t always so clearly defined. In fact, during the initial rise in individual cigarette use, the possibility that they contributed to lung cancer was laughable to some, derided by others.

Dr Evarts Graham, a pioneer of lung cancer surgery, openly scolded one of his colleagues and former trainees, Dr Alton Oschner, for suggesting in 1939 that smoking cigarettes was a “responsible factor” for the rise in lung cancer he was seeing in his own clinic. Graham reportedly responded to this suggestion by stating, “Yes, there is a parallel between the sale of cigarettes and the incidence of cancer of the lung, but there is also a parallel between the sale of nylon stockings and the incidence of lung cancer.” In other words, social trends may come and go, but their link to the changing incidence of any medical diagnosis is likely only circumstantial.

Physicians and the public continued to be skeptical of the relationship between cigarettes and lung cancer as per capita cigarette consumption rose at a staggering rate in the 1930’s and 1940’s. This, of course, led to the tragic rise in lung cancer rates that lagged behind by approximately a 20- to 30-year period. Described in 1912 as among the rarest of all cancers, lung cancer rose from the ashes of cigarettes to become the most common cancer killer of men by 1955 and of women by about 1990.

Classic case control studies in 1950 by Richard Doll and A Bradford Hill and ironically by Evarts Graham himself and a medical student, Ernst Wynder, subsequently provided strong evidence linking cigarettes to lung cancer. Graham, after seeing Wynder’s initial figures outlining the clear correlation between cigarette use and lung cancer, is reported to have remarked, “It is possible that I may have to eat humble pie.” This unfortunately didn’t save Graham, himself a heavy smoker, from succumbing to lung cancer in 1957. It would be seven more years until the seminal Surgeon General’s report in 1964 alerted the nation to the risk of cigarettes and definitively declared a causative link between cigarettes and lung cancer.

Why should we relive such a story today? Surely in the rapidly moving world of modern science and research and of widespread dissemination of knowledge, such a debacle would never happen and we could easily get ahead of a social trend with any potential for staggering public health consequences. Unfortunately, that is not the case.

We are already well behind on the burgeoning epidemic of e-cigarettes and vaping. Recent articles from the New England Journal of Medicine and from Lancet Respiratory Medicine confirmed that vaping, essentially a non-existent habit in 2011, has continued to increase dramatically in teenagers. In 2018, according to survey data, 16% of 10th graders and 21% of 12th graders had vaped nicotine within the past 30 days. In what is perhaps the best indicator that we are not doing enough to address this crisis, those rates had increased 8% and 10% respectively from 2017, rates which, when applied nationally, translated to a staggering 1.3 million new adolescent vapers in just one year. Personally, I have already heard enough when my eighth-grade son explicitly details the vaping habits of some of his classmates along with their distribution network.

This increased incidence of vaping in adolescents comes despite a general lack of knowledge about the long-term effects of e-cigarettes and vaping on lung heath and lung cancer. Certainly, some researchers are trying. Recent reports have demonstrated that e-cigarette vapors can have booster effects on carcinogen-bioactivating enzymes and that DNA damage occurs after long term inhalation, both precursor events to cancer.

The high temperature reached by e-cigarette solutions can also generate numerous toxic substances which get inhaled directly into the lungs. These substances cause lung inflammation, another well-known precursor to cancer and other lung diseases. E-cigarette vapor may disable protective immune cells in the lung, cells which are vital to the clearance of harmful particles from the lungs and which may have a role in surveillance against precancerous cells. All of these effects are magnified with the addition of nicotine to the vapor.

Although many teenagers may vape with just “flavoring”, a high proportion of vaping teens are also using e-cigarettes for the nicotine, which should justifiably raise fears that vaping will become a gateway for long-term addiction and potentially for transition to regular cigarette use. Shockingly, a single JUUL cartridge may contain as much nicotine as a whole pack of regular cigarettes. A real public health concern over the risk of nicotine addiction should therefore be front and center in the e-cigarette debate.

Fortunately, policy makers are beginning to rise to the task. Scott Gotlieb, the Food and Drug Administration Commissioner, has begun to target flavoring and marketing practices that appeal to adolescents and has warned that further regulatory restrictions are forthcoming. Such actions should be applauded. As a society, we have to get ahead of this issue. The e-cigarette industry is clearly not going to regulate itself, much like big tobacco before it. E-cigarettes should be treated as medications to aid smoking cessation (where they likely have a real role and potential benefit) and subjected to the same rigorous regulations that govern development, approval, and prescribing practices of other medications.

We remain shockingly ignorant about what the combustible liquids within e-cigarettes actually contain. We already made that mistake with tobacco and cigarettes. Without a doubt turning a blind eye and minimizing the risks of tobacco hurt people – our family members, our friends, and our colleagues – and helped to inflict an enormous cancer burden on them and upon our society. There are few things as heartbreaking as seeing the regret and self-blame of a former smoker newly diagnosed with lung cancer long after he or she got wise and gave up their cigarettes. Let’s not repeat those mistakes and regrets with e-cigarettes and vaping.

Dr Brendon Stiles is a cardiothoracic surgeon at New York-Presbyterian/Weill Cornell medical center and the chair of the Lung Cancer Research Foundation. Steve Alperin is the CEO of SurvivorNet, a media outlet for cancer information

https://whyquit.com/joels-videos/kids-and-vaping-an-ounce-of-prevention-is-worth-a-pound-of-cure/

Published 1:00 PM ET Mon, 11 Feb 2019 Updated 6:41 PM ET Mon, 11 Feb 2019

https://www.cnbc.com/2019/02/11/e-cigarettes-single-handedly-drives-spike-in-teen-tobacco-use-cdc.html?fbclid=IwAR2jGMZMFU7UOD6rQeDWlcAsOjD_Xt38fifTrTrwEGlbuBTxCcu8-MtSFNI

CDC blames spike in teen tobacco use on vaping, popularity of Juul

• Over the course of a year, the number of high school students using tobacco products increased by about 38 percent, the Centers for Disease Control and Prevention found.
• E-cigarettes drove the increase, the CDC said. Use of other products remained stable.
• In 2018, nearly 21 percent of high school students, or 3 million, vaped.

The Centers for Disease Control and Prevention is blaming nicotine vaping devices like Juul for single-handedly driving a spike in tobacco use among teens, threatening to erase years of progress curbing youth use.

Over the course of a year, the number of high school students using tobacco products, which include e-cigarettes, increased by about 38 percent, the CDC found in its annual National Youth Tobacco Survey released Monday. That translates to about 27 percent of high school teens using tobacco products in 2018, the CDC said.

Of all the tobacco products the CDC surveys students about, including cigarettes and hookah, only e-cigarettes saw a meaningful increase in use. Among high school students, e-cigarette use surged nearly 78 percent. In 2018, nearly 21 percent of high school students vaped, up from close to 12 percent in 2017.

In 2018, 1.5 million more middle school and high school students vaped than in 2017, up to 3.6 million from 2.1 million, according to the survey.

While the survey did not specifically ask teens about Juul, Brian King, deputy director for research translation in the CDC's Office on Smoking and Health, said the increase in e-cigarette use coincides with the rise in sales of Juul's products.

Teens are also vaping more frequently than before. About 28 percent of teens who are vaping are doing it 20 or more times per month, a 39 percent increase from the 20 percent of teens who were defined as frequent users in 2017, the CDC said.

About 40 percent of high school students who said they used tobacco said they used two or more types of products, a 23 percent increase. About 15 percent of them vaped and smoked cigarettes, according to the survey.

The data confirms anecdotal reports that more and more teens have started to use e-cigarettes, particularly Juul. Public health officials, including the CDC, the Food and Drug Administration and the surgeon general, have warned that the trend could reverse two decades of driving down teen smoking rates.

"The skyrocketing growth of young people's e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use," CDC Director Robert Redfield said in a statement. "It's putting a new generation at risk for nicotine addiction."

Among other tobacco products, including cigarettes and cigars, the CDC did not find any significant change. That means e-cigarettes were the sole driver of the increase in overall tobacco use, the agency said. E-cigarettes surpassed cigarettes to become the most commonly used form of tobacco among middle school and high school students in 2014.

More high school students vape than smoke cigarettes

The rate of high school students using e-cigarettes eclipsed the rate of those smoking cigarettes in 2014, according to the CDC's National Youth Tobacco Survey

Cigarette smoking among high school students ticked up to 8.1 percent from 7.6 percent. It's not a statistically significant rise, but it still has some concerned.

"These survey results are deeply troubling," Matthew Myers, president of the Campaign for Tobacco-Free Kids, said in a statement. "They add to mounting concerns that the rise in youth use of e-cigarettes, especially Juul, is vastly expanding the number of kids addicted to nicotine, could be leading kids to and not away from cigarettes, and directly threatens the decades-long progress our nation has made in reducing youth smoking and other tobacco use."

The Centers for Disease Control and Prevention is blaming nicotine vaping devices like Juul for single-handedly driving a spike in tobacco use among teens, threatening to erase years of progress curbing youth use.

Over the course of a year, the number of high school students using tobacco products, which include e-cigarettes, increased by about 38 percent, the CDC found in its annual National Youth Tobacco Survey released Monday. That translates to about 27 percent of high school teens using tobacco products in 2018, the CDC said.

JUUL institutes enhanced age verification for online sales   3:02 PM ET Tue, 13 Nov 2018 | 01:56

Of all the tobacco products the CDC surveys students about, including cigarettes and hookah, only e-cigarettes saw a meaningful increase in use. Among high school students, e-cigarette use surged nearly 78 percent. In 2018, nearly 21 percent of high school students vaped, up from close to 12 percent in 2017.

In 2018, 1.5 million more middle school and high school students vaped than in 2017, up to 3.6 million from 2.1 million, according to the survey.

While the survey did not specifically ask teens about Juul, Brian King, deputy director for research translation in the CDC's Office on Smoking and Health, said the increase in e-cigarette use coincides with the rise in sales of Juul's products.

Teens are also vaping more frequently than before. About 28 percent of teens who are vaping are doing it 20 or more times per month, a 39 percent increase from the 20 percent of teens who were defined as frequent users in 2017, the CDC said.

About 40 percent of high school students who said they used tobacco said they used two or more types of products, a 23 percent increase. About 15 percent of them vaped and smoked cigarettes, according to the survey.

The data confirms anecdotal reports that more and more teens have started to use e-cigarettes, particularly Juul. Public health officials, including the CDC, the Food and Drug Administration and the surgeon general, have warned that the trend could reverse two decades of driving down teen smoking rates.

"The skyrocketing growth of young people's e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use," CDC Director Robert Redfield said in a statement. "It's putting a new generation at risk for nicotine addiction."

Among other tobacco products, including cigarettes and cigars, the CDC did not find any significant change. That means e-cigarettes were the sole driver of the increase in overall tobacco use, the agency said. E-cigarettes surpassed cigarettes to become the most commonly used form of tobacco among middle school and high school students in 2014.

Cigarette smoking among high school students ticked up to 8.1 percent from 7.6 percent. It's not a statistically significant rise, but it still has some concerned.

"These survey results are deeply troubling," Matthew Myers, president of the Campaign for Tobacco-Free Kids, said in a statement. "They add to mounting concerns that the rise in youth use of e-cigarettes, especially Juul, is vastly expanding the number of kids addicted to nicotine, could be leading kids to and not away from cigarettes, and directly threatens the decades-long progress our nation has made in reducing youth smoking and other tobacco use."

Surgeon General Jerome Adams has declared youth e-cigarette use an epidemic. The FDA is trying to limit illegal sales to minors. The agency is drafting new rules that would limit flavored nicotine pods to age-restricted stores like vape shops. The agency plans to publish the proposed regulation within the next month, Commissioner Scott Gottlieb told CNBC last week.

Gottlieb said Monday that the FDA is also exploring possible civil and criminal enforcement tools "to target potentially violative sales and marketing practices by manufacturers as well as retailers."

"These trends require forceful and sometimes unprecedented action among regulators, public health officials, manufacturers, retailers and others to address this troubling problem," Gottlieb said in a statement.

Juul spokeswoman Victoria Davis said the company is "committed to fighting underage use of vaping products, including Juul products."

Stanton A. Glantz, PhD

https://tobacco.ucsf.edu/new-evidence-e-cigs-pose-substantial-risks-adult-asthma-and-copd-similar-cigarettes?fbclid=IwAR2JN2Zs7JirmTnSfAJLHsO-1xb13bt_fV8IxIJT8PyyEQReJN3s_GpUFmM

New evidence that e-cigs pose substantial risks of adult asthma and COPD similar to cigarettes

Tom Wills and colleagues just published “E-cigarette use and respiratory disorder in an adult sample,” documenting the link between e-cigarette use and asthma and chronic obstructive pulmonary disease, controlling for smoking among a large sample of Hawaiians.  The found e-cigs increase the risk of COPD by a factor of 2.58, with dual users (people use e-cigarettes and cigarettes at the same time) higher than using cigarettes or e-cigarettes alone.  They found similar risks for e-cigarettes, cigarettes, and dual use for asthma.

This figure, from their paper, makes these points nicely.  Note that the lines for e-cigarettes, cigarettes, and dual use all fall on top of each other, above the line for nonsmokers.  For COPD, the risks of e-cigarettes and cigarettes are similar, with dual use above both of them.

The COPD results for dual use are particularly important since about 70% of e-cigarette users continue to smoke (i.e., are dual users).  It adds to the case that, in terms of respiratory disease, e-cigarettes are about as bad as cigarettes, but also are different from cigarettes and add to the risk of smoking.  (This is the same finding we found for heart attacks.)

These results are consistent with an earlier study using PATH showing that e-cigarette users were at higher risk of COPD, controlling for smoking.

Here is the abstract:

OBJECTIVES:  Little evidence is available on the association of e-cigarettes with health indices. We investigated the association of e-cigarette use with diagnosed respiratory disorder among adults in data from the Behavioral Risk Factor Surveillance Survey (BRFSS).

METHODS: The 2016 Hawaii BRFSS, a cross-sectional random-dial telephone survey, had 8087 participants; mean age was 55 years. Items asked about e-cigarette use, cigarette smoking, and being diagnosed by a health professional with (a) asthma or (b) chronic obstructive pulmonary disease. Multivariable analyses tested associations of e-cigarette use with the respiratory variables controlling for smoking and for demographic, physical, and psychosocial variables.

RESULTS:  Controlling for the covariates and smoking there was a significant association of e-cigarette use with chronic pulmonary disorder in the total sample (AOR = 2.58, CI 1.36-4.89, p < 0.01) and a significant association with asthma among nonsmokers (AOR = 1.33, CI 1.00-1.77, p <  0.05). The associations were stronger among nonsmokers than among smokers. Results were similar for analyses based on relative risk and absolute risk. There was also a greater likelihood of respiratory disorder for smokers, females, and persons with overweight, financial stress, and secondhand smoke exposure.

CONCLUSIONS:  This is the first study to show a significant independent association of e-cigarette use with chronic respiratory disorder. Several aspects of the data are inconsistent with the possibility that e-cigarettes were being used for smoking cessation by persons with existing respiratory disorder. Theoretical mechanisms that might link e-cigarettes use and respiratory symptoms are discussed.

The full citation is:  Wills TA, Pagano I, Williams RJ, Tam EK.  E-cigarette use and respiratory disorder in an adult sample.  Drug Alcohol Depend. 2019 Jan 1;194:363-370. doi: 10.1016/j.drugalcdep.2018.10.004. Epub 2018 Nov 7.  It is available here.

Stanton A. Glantz, PhD

https://tobacco.ucsf.edu/rct-comparing-e-cigs-nrt-shows-effectiveness-supervised-smoking-cessation-program-what-it-does-and-does-not-mean?fbclid=IwAR3BTV8SJ13deT_tMOiQFOhcidWO1jEkakN-ynQbJtIxNJ4gprzkn0OMZvY

RCT comparing e-cigs to NRT shows effectiveness in a supervised smoking cessation program: what it does and does not mean

February 4, 2019

Stanton A. Glantz, PhD

RCT comparing e-cigs to NRT shows effectiveness in a supervised smoking cessation program: what it does and does not mean

Peter Hajek and colleagues published “A Randomized Trial of E-cigarettes versus Nicotine-Replacement Therapy” in the New England Journal of Medicine.  This is a well-done trial comparing e-cigarettes with nicotine replacement therapy among people enrolled in smoking cessation programs in England.  In addition to being randomized to e-cigs or NRT, people in the study had at least 4 weeks of counseling.  At one year the cigarette abstinence rate was 18.0% among patients randomized to e-cigs compared to 9.9% randomized to NRT, nearly a doubling of quitting.

The study is thoughtfully designed and cautiously interpreted.  The authors also did a nice set of sensitivity analyses to show that the results are robust to the usual kinds of problems one has in doing a randomized controlled trial.

They conclude that “E-cigarettes were more effective for smoking cessation that nicotine-replacement therapy, when both products were accompanied by behavioral support.”  I agree with that conclusion.

Having said that, it is important to emphasize that this is not a study of e-cigarettes as most people use them, which is as recreational products not as part of a clinically supervised cessation attempt that, most important, includes intensive counseling.   Thus, the results of the Hajek study do not contradict the overall result that, in the general population, smokers who use e-cigarettes are, on average, less likely to quit smoking.

So, my bottom line is that if other well-done randomized controlled trials show that e-cigarettes improve smoking cessation, the manufacturers should submit the evidence to the appropriate authorities (the FDA in the USA) to get e-cigarettes approved as prescription medicines to be administered by physicians or other health professionals as part of supervised cessation efforts that include intensive counseling. 

The reason that I say they should be available by prescription is because of their high abuse potential, as evidenced by the run-away use of them by kids as well as the fact that when used unsupervised in the general population they depress smoking cessation.

In addition to efficacy, the drug approval process needs to assess safety.  Hajek and colleagues reported that after one year 80% of the e-cigarette group were still using e-cigarettes compared to just 9% of the NRT group were continuing to use NRT.  This is of particular concern because of the evidence linking e-cigarette use to heart attacks and chronic obstructive pulmonary disease and is something that warrants serious consideration by regulatory authorities.

The accompanying editorial by Belinda Borrelli and George T. O’Connor also raises several concerns about long-term safety of e-cigarette use and notes that varenicline -- which was not evaluated in the Hajek study -- outperforms NRT.

Here is the abstract:

BACKGROUND:  E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments.

METHODS: We randomly assigned adults attending U.K. National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks. The primary outcome was sustained abstinence for 1 year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms.

RESULTS: A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath.

CONCLUSIONS:  E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support. (Funded by the National Institute for Health Research and Cancer Research UK; Current Controlled Trials number, ISRCTN60477608 .).

The full citation is Hajek P, et al.  A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy.  N Engl J Med. 2019 Jan 30. doi: 10.1056/NEJMoa1808779. [Epub ahead of print].   The paper is available here.