Vaping advocates like to point to lists of agencies which support the proliferation of vaping as a way of helping smokers quit and reducing harm. They hope that uninformed readers will take from such lists that there is now virtual consensus that nicotine vaping products are established to be safe and effective, and that many august bodies have now concluded that the jury has returned with a resounding global verdict.

These lists rarely include statements from agencies who remain far from  convinced that vaping products indeed live up to the hype that their commercial and often financially supported consumer interest groups wish to see dominate public and political narratives.

Some of these interest groups have very deep pockets which enable them to pay for lavish advertising, promotional, and public relations campaigns and to fund third party groups and individuals to proselytise on their behalf, with their financial connections are often either buried deep in links within links in the fine print of websites or undeclared.

This blog post provides a list of international and national agencies and collections of researchers and public health agencies which have expressed significant concerns about e-cigarettes and other heat-not-burn nicotine delivery products.

I have provided indicative examples of cautious and sceptical statements, with links to their full reports or statements. I will update it regularly with those I have missed and as more statements are published or revised.

I’d be grateful for notification of any such additions via the comment facility on this page. [updated 30 May 2019; 3 Jun 2019]

International Agencies

Forum of International Respiratory Societies (including American College of Chest Physicians, the American Thoracic Society, the Asian Pacific Society of Respirology, Asociación Latinoamericana del Tórax, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease, the Pan African Thoracic Society, the Global Initiative for Asthma, and the Global Initiative for Chronic Obstructive Lung Disease) (2014 and 2018)

The Forum of International Respiratory Societies is composed of professional organisations and experts in respiratory disease. Member societies include Asociacio´n Latinoamericana del To´rax, the American College of Chest Physicians, the American Thoracic Society, the Asian Pacific Society of Respirology, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease and the Pan African Thoracic Society.

• The health risk of electronic cigarettes has not been adequately studied.  (2014)
• Potential benefits to an individual smoker should be weighed against harm to the population of increased social acceptability of smoking and use of nicotine.  (2014)
• Electronic nicotine delivery devices should be restricted or banned, at least until more information about their safety is available. (2014)
• There can be no argument for harm reduction in children. To protect this vulnerable population from electronic cigarettes and other nicotine delivery devices, we recommend that electronic cigarettes be regulated as tobacco products and included in smoke-free policies. Sale of electronic cigarettes should be barred to youths worldwide. Flavouring should be prohibited in electronic cigarettes, and advertising accessible by youths and young adults be banned. (2018)

International Union Against Tuberculosis and Lung Disease  (2013 and 2014)

Key messages of the 2014 statement include:

• The safety of electronic cigarettes (ECs) or electronic nicotine delivery systems (ENDS) has not been scientifically demonstrated.
• Adverse health effects for third parties exposed (second-hand exposure) cannot be excluded because the use of ECs leads to the emission of fine and ultrafine inhalable liquid particles, nicotine and cancer-causing substances into indoor air.
• The benefits of ECs have not been scientifically proven. To date, few studies have assessed ECs/ENDS as a harm reduction and cessation aid; those that do exist have conflicting findings.
• The tobacco transnationals have increasingly entered the EC/ENDS marketplace with a strong presence.
• ENDS could undermine the implementation of the WHO Framework Convention on Tobacco Control (FCTC) Article 12 (de-normalisation of tobacco use); use of ENDS could also hamper the implementation of Article 8 (protection from exposure to tobacco smoke), as ENDS users in public places may claim that their electronic cigarette does not contain tobacco and/or does not produce second-hand tobacco smoke.
• The Union strongly supports regulating the manufacturing, marketing and sale of ECs or ENDS, preferably as medicines.

World Federation of Public Health Associations  (2018)

The World Federation of Public Health Associations has 123 member organisations. It supports recommendations provided by the WHO in their 2014 report.

World Medical Association (2012)

The World Medical Association is a federation of 111 national medical associations, including the Australian Medical Association. In their 2012 statement Electronic igarettes and other electronic nicotine delivery systems, the WMA recommended:

• That the manufacture and sale of e-cigarettes and other electronic nicotine delivery systems be subject to national regulatory bodies prior approval based on testing and research as either a new form of tobacco product or as a drug delivery device.
• That the marketing of e-cigarettes and other electronic nicotine delivery systems as a valid method for smoking cessation must be based on evidence and must be approved by appropriate regulatory bodies based on safety and efficacy data.
• That e-cigarettes and other electronic nicotine delivery systems be included in smoke free laws.
• Physicians should inform their patients of the risks of using e-cigarettes even if regulatory authorities have not taken a position on the efficacy and safety of these products.

World Health Organization and the Framework Convention on Tobacco Control  (FCTC)

In October 2014, the WHO presented its report Electronic nicotine delivery systems to the Sixth Session of the FCTC Conference of the Parties in Moscow. The report included the following clauses:

General considerations (clauses 33–38)

33. Smokers will obtain the maximum health benefit if they completely quit both tobacco and nicotine use. In fact, Article 5.2(b) of the Convention commits Parties not only to preventing and reducing tobacco consumption and exposure to tobacco smoke but also to preventing and reducing nicotine addiction independently from its source. Therefore, while medicinal use of nicotine is a public health option under the treaty, recreational use is not.
34. The rapid growth of ENDS use globally can neither be dismissed nor accepted without efforts to appropriately regulate these products, so as to minimize consequences that may contribute to the tobacco epidemic and to optimize the potential benefits to public health. Thus it is important to identify public health concerns and to consider these concerns when undertaking regulation and surveillance.
35. Regulation of ENDS is a necessary precondition for establishing a scientific basis on which to judge the effects of their use, and for ensuring that adequate research is conducted, that the public has current, reliable information as to the potential risks and benefits of ENDS, and that the health of the public is protected. Public health authorities need to prioritize research and invest adequately to elucidate evidentiary uncertainties as soon as possible. However, the greater responsibility to prove claims about ENDS scientifically should remain with the industry.
36. When designing a regulatory strategy for ENDS, governments should bear in mind the following general regulatory objectives:

(a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth;

(b) minimize potential health risks to ENDS users and non-users;

(c) prohibit unproven health claims from being made about ENDS; and

(d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry.

37. Because the product, the market and the associated scientific evidence surrounding ENDS are all evolving rapidly, all legislation and regulations related to ENDS should be adaptable in response to new scientific evidence, including evaluation of different models for ENDS regulation, as evidence accumulates.

The decision following the report:

Invites Parties to consider applying regulatory measures such as those referred to in document FCTC/COP/7/11 to prohibit or restrict the manufacture, importation, distribution, presentation, sale and use of ENDS/ENNDS, as appropriate to their national laws and public health objectives.

Australian Agencies

Australian Competition & Consumer Commission (Product Safety Australia)

“No assessment of the safety and quality of electronic cigarettes has been undertaken. If liquid nicotine is imported for uses other than therapeutic, it is considered a substance that may cause harm and requires special precautions in manufacture, handling or use.”

Australian Council on Smoking and Health (March 2019)

“there is insufficient evidence to recommend e-cigarettes as a safe and efficacious method to give up smoking. It is also important to note that we are now seeing increasing evidence of harms attributable to their use. It is also important to emphasise that there is now also convincing evidence that the use of e-cigarettes by children and young people is an on-ramp for the use of traditional cigarettes. In recent months, the US Surgeon General, Secretary for Health and Commissioner of the Food and Drug Administration have sounded an alarm about the “epidemic” of vaping there by adolescents.”

Australian Dental Association (July 2017)

“The ADA’s review of the research literature finds that much more research must occur to confirm whether the use of ecigarettes/PV/ENDS assists people to quit smoking and does not cause further health impacts… many of these devices are being presented to the market as the ‘healthy’ alternative to smoking or claim to help people quit smoking. However, ENDS, of which e-cigarettes are one example, have not been rigorously assessed for efficiency and safety by the Therapeutic Goods Administration (TGA) and therefore the quality and safety is unknown. … The model taken to regulate the marketing of e-cigarettes and personal vaporisers should mirror those that pertain to the smoking of tobacco products. With the body of scientific and clinical research about the health impacts of e-cigarettes/personal vaporisers still in their early stages of infancy, the Australian Government should draw from lessons pertaining to public policy debates regarding the health impacts of tobacco products in the 20^th century.The ADA urges the Australian Government to adopt in the precautionary principle and adopt the same regulations that underpin the use, manufacturing and marketing of tobacco products; applying them to e-cigarettes and personal vaporisers and ENDS.”

Australian Medical Association (2015)

“The evidence supporting the role of e-cigarettes in cessation is mixed and low level, and e-cigarettes are not currently recognised as cessation aids by the National Health and Medical Research Council, the Therapeutic Goods Administration or the World Health Organisation. In fact, using an e-cigarette may significantly delay the decision to quit smoking.  In addition, there is uncertainty about the longer term health implications of inhaling the vapours produced by the illegally imported (and unregulated) solutions.”

Cancer Council Australia, Heart Foundation and Cancer Australia (Feb 2018 joint policy)

“Based on current evidence, the potential benefit of e-cigarettes on smoking cessation is not established, and there is increasing evidence of health harms.”

CSIRO (Commonwealth Scientific and Industrial Research Organisation) (Jun 2018)

• The evidence available suggests that regular use of e-cigarettes is likely to have adverse health consequences.

• The evidence is consistent in suggesting that use of e-cigarettes by non-smoking youth predicts future smoking.
• While many smokers and former smokers state a preference for e-cigarettes as a smoking cessation method, the effectiveness of this method compared with other smoking cessation methods is not known.

• Based on the current evidence it is not possible to ascertain whether e-cigarettes have a positive or a negative effect on health in countries where they are permitted.
• On present evidence, it is not possible to determine whether less restrictive access to e-cigarettes would reduce rates of smoking in Australia.

Lung Foundation Australia  (2014)

“There is currently not enough evidence to suggest the use of e-cigarettes as an effective smoking cessation tool over current recommended strategies including pharmacotherapy and clinical counselling. This could change as more research is published on this subject.

While the number of toxins in an e-cigarette is fewer than those in traditional cigarettes, there are no long-term studies on the safety of e-cigarettes and concern has been expressed about the small particles inhaled when “vaping” and their health impact, particularly on youth.

Members noted that the current evidence base in relation to e-cigarettes supports maintaining and, where appropriate, strengthening the current controls that apply to the marketing and use of these products in Australia. Members agreed to national guiding principles which reflect a precautionary approach to e-cigarettes and affirmed the current national regulatory framework remains appropriate.” 

National Health & Medical Research Council (2017)

E-cigarettes may expose users to fewer toxic chemicals than conventional tobacco cigarettes; however the extent to which this reduces harm to the user has not been determined; There is currently insufficient evidence to conclude whether e-cigarettes can assist smokers to quit; There is some evidence from longitudinal studies to suggest that e-cigarette use in non-smokers is associated with future uptake of tobacco cigarette smoking.

Ministerial Drug and Alcohol Forum (27 Nov 2017)

Parliament of Australia. House of Representatives. Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia

The Committee recommends that the Therapeutic Goods Administration continues to oversee the classification of nicotine and relevant exemptions, and the assessment of any electronic cigarette product as a therapeutic good.

The Committee recommends that the Australian Government establish a regulatory process for assessing and, if necessary, restricting colourings and flavourings used in electronic cigarettes.

Public Health Association of Australia (2018)

Based on current evidence, and in line with recommendations from the WHO, the World Federation of Public Health Associations, the Cancer Council, Heart Foundation, Cancer Australia and other leading evidence-based organisations, the PHAA strongly supports a precautionary approach to the use, promotion and availability of e-cigarettes in Australia

Royal Australian College of General Practitioners (July 2014)

“Concerns about e-cigarettes include a lack of evidence for short-term efficacy and short-and long-term safety, particularly in patients with current chronic disease. Rather than cessation, concurrent use with smoking may continue. There are also concerns that e-cigarettes may potentially act as a gateway to smoking.163 However it is reasonable to conclude that if used as a substitute rather than an addition, e-cigarettes are much less harmful than continuing to smoke.”

Royal Australasian College of Physicians (May 2018)

“The RACP is concerned there remains a lack of clear and robust evidence to inform policy makers, clinicians and the public about e-cigarettes. While there is some evidence that e-cigarettes mayreduce the number of tobacco cigarettes smokers consume and that they are likely to be less harmful than tobacco cigarettes (due to lower level of potentially toxic substances in e-cigarettes compared with tobacco cigarettes), the evidence on their efficacy as aids in smoking cessation and their long-term health effects is either mixed or limited. There is also evidence indicating that their use affects the likelihood of youth initiating use of tobacco cigarettes. Based on the current evidence, at this point in time the net public health effect of e-cigarettes cannot be clarified with any degree of confidence. The RACP acknowledges that e-cigarettes may have a potential role in tobacco harm reduction and smoking cessation for smokers unable or unwilling to quit. However, due to lack of long-term data and large population studies, e-cigarettes should be treated with caution. Users should be aware when using a nicotine-containing e-liquid that nicotine is highly addictive and a poison. Any e-cigarette that claims therapeutic benefit (including smoking cessation) must undergo the appropriate regulatory approval pathway in order to be allowed to make such claims, by either the Australian Therapeutic Goods Administration or in New Zealand, Medsafe.

The RACP is of the view that e-cigarettes present no benefits and only potential harms to those who do not smoke, be they never smokers or former smokers. We are concerned that the use of e-cigarettes may increase the likelihood of tobacco smoking initiation, in particular among adolescents and young people, as indicated in some evidence. In view of this, the sale, supply, promotion and useof e-cigarettes must be effectively regulated and they should not be available to minors. E-cigarettes should be included within smoke-free environment legislation, primarily due to the potential harms from re-normalising smoking and the exposure to second-hand e-cigarette aerosol.”

Therapeutic Goods Administration (2015)

“Unlike Nicotine Replacement Therapy (NRT) products, which have been rigorously assessed for efficacy and safety and, therefore, approved by the Therapeutic Goods Administration for use as aids in withdrawal from smoking, no assessment of electronic cigarettes has been undertaken and, therefore, the quality and safety of electronic cigarettes is not known.

The Australian Government is concerned about the use of electronic cigarettes in Australia. The impact of wide-scale use of these devices on tobacco use is not known, and the outcome in the community could be harmful.”

Thoracic Society of Australia and New Zealand (2017 joint statement with Lung Foundation Australia)

{There is no good public health claim for an unregulated approach to e-cigarettes and personal vaporisers. There is a strong case for a total ban on these products as they are currently available. Currently, e-cigarettes and personal vaporisers are being marketed as a harmless life choice, without any cautionary labels or health warnings. The use of these devices causes injury to the lung. There is no reason to support an approach to regulating a product which causes ill health, contains known carcinogens and other toxic compounds. The most compelling argument for these devices, and it is an argument based on anecdotal and personal experiences rather than an evidence base, is for use in smoking cessation. It is likely that these devices are less harmful than smoking cigarettes, however they are not harmless. If they are to be used as cessation aids, then this is a therapeutic device and must be regulated as such by the Therapeutic Good Administration.”

VicHealth (July 2017)

• ECPVs should only be made available as a smoking cessation aid if they are approved by the Therapeutic Goods Administration (TGA).
• ECPVuse should be subject to the same restrictions as tobacco smoking,and therefore should not be permitted in existing smoke-free areas.
• ECPVs should only be marketed as a therapeutic good if approved by the TGA.

US Agencies

American Academy of Family Physicians (April 2019)

“There are concerns about the lack of any regulatory oversight by the Food and Drug Administration’s Center for Tobacco Products on the manufacture, distribution and safety of e-cigarettes. Therefore, the AAFP calls for rigorous research in the form of randomized controlled trials of e-cigarettes to assess their safety, quality, and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of e-cigarettes, especially to children and youth, should cease immediately until e-cigarette’s safety, toxicity, and efficacy are established.”

American Academy of Pediatrics (2018) 

“Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among youth. The 2016 US Surgeon General’s Report on e-cigarette use among youth and young adults concluded that e-cigarettes are unsafe for children and adolescents. Furthermore, strong and consistent evidence finds that children and adolescents who use e-cigarettes are significantly more likely to go on to use traditional cigarettes—a product that kills half its long-term users. E-cigarette manufacturers target children with enticing candy and fruit flavors and use marketing strategies that have been previously successful with traditional cigarettes to attract youth to these products. Numerous toxicants and carcinogens have been found in e-cigarette solutions. Nonusers are involuntarily exposed to the emissions of these devices with secondhand and thirdhand aerosol. To prevent children, adolescents, and young adults from transitioning from e-cigarettes to traditional cigarettes and minimize the potential public health harm from e-cigarette use, there is a critical need for e-cigarette regulation, legislative action, and counterpromotion to protect youth.”

American Association for Cancer Research & American Society of Clinical Oncology (joint statement Jan 2015)

“ENDS may be beneficial if they reduce smoking rates or prevent or reduce the known adverse health effects of smoking. However, ENDS may also be harmful, particularly to youth, if they increase the likelihood that nonsmokers or formers smokers will use combustible tobacco products or if they discourage smokers from quitting. The American Association for Cancer Research (AACR) and the American Society of Clinical Oncology (ASCO) recognize the potential ENDS have to alter patterns of tobacco use and affect the public’s health; however, definitive data are lacking. AACR and ASCO recommend additional research on these devices, including assessing the health impacts of ENDS, understanding patterns of ENDS use, and determining what role ENDS have in cessation. Key policy recommendations include supporting federal, state, and local regulation of ENDS; requiring manufacturers to register with the FDA and report all product ingredients, requiring childproof caps on ENDS liquids, and including warning labels on products and their advertisements; prohibiting youth-oriented marketing and sales; prohibiting child-friendly ENDS flavors; and prohibiting ENDS use in places where cigarette smoking is prohibited.”

American Cancer Society Cancer Action Network (Feb 2018) 

“The ACS strongly recommends that every effort be made to prevent the initiation of e-cigarettes by youth.  The use of products containing nicotine in any form among youth is unsafe and can harm brain development. Furthermore, evidence indicates that young e-cigarette users are at increased risk for both starting to smoke and becoming long-term users of combustible tobacco products.

The ACS encourages the FDA to regulate all tobacco products, including e-cigarettes, to the full extent of its authority, and to determine the absolute and relative harms of each product.  The FDA should assess whether e-cigarettes help to reduce tobacco-related morbidity and mortality, and the impact of marketing of e-cigarettes on consumer perceptions and behavior.  Any related regulatory regime should include post-marketing surveillance to monitor the long-term effects of these products and ensure the FDA’s actions have the intended health outcome of significantly reducing disease and death.  Furthermore, the FDA should use its authorities to reduce the toxicity, addictiveness and appeal of tobacco products currently on the market.  The ACS also applauds the FDA for recognizing its significant role as a science-based agency in helping to address the addictiveness of nicotine in cigarettes.  Reducing nicotine in all combustible tobacco products to below addictive levels holds the potential to significantly accelerate reductions in the use of combustible tobacco products, which remain by far the leading preventable cause of cancer and preventable death in the United States.” 

American College of Cardiology (Nov 2018)

“Traditional cigarettes are an often-lifelong habit with major health implications that usually begins in adolescence. According to the CDC, youth who use e-cigarettes may be more likely to smoke in the future. When the latest e-cigarettes are designed to almost mimic a flash drive and feature flavors like strawberry and chocolate, it’s not hard to see why they’re on the rise among American youth. It is the responsibility of the health community—public organizations, medical societies and even individual clinicians—to make it less likely American children become smokers. Furthermore, we have concerns about the widespread use of a product for which, frankly, the medical and scientific community has yet to clearly establish the long-term health implications ”

American College of Physicians (Dec 2018)

“ACP’s 2015 policy paper, Electronic Nicotine Delivery Systems, highlighted the dangers that ENDS products, including e-cigarettes, present to individuals, particularly minors, and called for a ban on flavored tobacco products, which often attract minors. ACP is especially concerned about the increase in ENDS use among young people, as evidence suggests that adolescents who start using ENDS also use, or intend to use, combustible tobacco products later in life.

ACP is committed to supporting regulations that will reduce the use of all forms of tobacco products, including e-cigarettes. ACP looks forward to continuing to work with regulators and health care stakeholders to implement meaningful policy that will not only improve public health, but will take concrete steps towards combating the epidemic of ENDS use among young people.”

American College of Preventive Medicine (Jan 2019)

“The evidence behind the safety and efficacy of ENDS has not caught up with the rapid increase in widespread use of these products. Limited evidence supports the short-term efficacy of exclusive use of nicotine-containing ENDS in adults desiring to quit, with several RCTs demonstrating positive results compared with observational studies that often do not show benefit. These studies compared ENDS with no treatment, non-nicotine ENDS, or, in rare cases, NRT. There is insufficient evidence comparing the efficacy of ENDS to established evidence-based treatments.

The evidence on the benefits versus harms of e-cigarettes is still emerging. There are significant population health concerns, and it is unclear if the potential benefit to the individual adult smoker interested in quitting outweighs the potential harms of attractiveness to youth, including a gateway to cigarette smoking and changing norms around vaping and smoking.

On an individual level, limited evidence suggests that ENDS may be effective at reducing cigarette use among adult smokers intending to quit. There is insufficient evidence addressing potential long-term harms of ENDS, and limited evidence is available about short-term harms of ENDS and the impact of secondhand exposure. Although ENDS appear safer than combustible cigarettes, they are not without risk. Among youth there is no known benefit and significant concern for harm. On a population level, there may be significant harms associated with ENDS, particularly among youth nonsmokers. The long-term balance of potential benefits versus harms from the individual and population perspectives are unclear.”

American Lung Association (Feb 2019)

“The American Lung Association is very concerned that we are at risk of losing another generation to tobacco-caused diseases as the result of e-cigarettes. The Lung Association remains extremely troubled about the rapid increase of youth using these products and has repeatedly called upon the Food and Drug Administration (FDA) to increase their oversight and scrutiny of these products to protect kids.”

American Heart Association (March 2019)

Policy positions:
All marketing and advertising of tobacco products, including e-cigarettes and other non-combustible products, should be restricted. This includes online, social, television, radio, and print ads, celebrity endorsements, movie placements, price promotions, event sponsorships and branding of non-tobacco merchandise.

The FDA’s Center for Drug Evaluation and Research should collaborate with the FDA’s Center for Tobacco Products on the research and legal analysis needed to facilitate e-cigarettes being regulated and sold only as FDA-approved cessation products.

American Medical Association (2018)

“Our AMA:

(1) recognizes the use of e-cigarettes and vaping as an urgent public health epidemic and will actively work with the Food and Drug Administration and other relevant stakeholders to counteract the marketing and use of addictive e-cigarette and vaping devices, including but not limited to bans and strict restrictions on marketing to minors under the age of 21;

(2) encourages the passage of laws, ordinances and regulations that would set the minimum age for purchasing tobacco products, including electronic nicotine delivery systems (ENDS) and e-cigarettes, at 21 years, and urges strict enforcement of laws prohibiting the sale of tobacco products to minors…” 

American Public Health Association (Nov 2018)

“The safety of ENDS and their efficacy in smoking cessation programs have not been demonstrated, and scientific evidence exists to the contrary. In the United States, ENDS use has increased among all demographic groups, including young people, vulnerable populations, and minorities. Studies suggest that ENDS use increases use of combustible tobacco, and chemicals are harmful to both users and those exposed to secondhand vapor. … APHA supports efforts to regulate ENDS, urges restriction of ENDS advertising and promotion, encourages prohibition of ENDS use in public places and workplaces, calls for evidence-based research regarding ENDS efficacy in smoking cessation, and recommends prohibiting the sale of ENDS to people 21 years and younger.”

American Society of Addiction Medicine (April 2018)

“The concern with the current situation is that e-cigarettes have largely not been tested or standardized, and products offered on the market are rapidly changing, making it difficult to assess true potential benefit for cessation or harm to the user in the long term. Available evidence suggests that harm from e-cigarettes is expected to be much lower than from combustible cigarettes, which are estimated to contain roughly one hundred times the amount of toxins.  However, there are other risks associated with e-cigarettes, as there are reports of these devices spontaneously exploding, causing burns and other injuries to users. They are banned from airline flights for this reason. Finally, other modifiable forms or “mods” that rely the on use of refillable liquid nicotine solutions are at risk for contamination with other substances since the production and manufacturing of these products are not tested or regulated by any government agency or held to any standard. …

An additional concern is the still-unknown risk to young people who are currently major consumers of electronic cigarettes in the US.  Although cigarette smoking continues to decrease among American teens, use of electronic cigarettes has been escalating and surpassed use of other forms of tobacco.  A study of middle and high school students found that, among those who were current users of tobacco products, an estimated 70.0% (3.26 million) had used at least one flavored tobacco product in the past 30 days.  The long-term effects of this are unknown. There are concerns that, as prevention efforts to educate children on the harms of tobacco in cigarettes had a positive impact on teen cigarette use, the tobacco industry has promoted alternative ways to attract teens to smoking by adding flavoring and engaging in direct advertising. These strategies coincide with the rise in e-cigarette use among youth, thereby increasing exposure and the potential for the development of addiction involving the use of nicotine. Lastly, there is a potential risk that e-cigarette use will be a gateway to subsequent combustible tobacco and other drug use, including marijuana; however, research findings on such long-term effects will not be available for some time.”

American Society of Clinical Oncology Joint Statement with American Association for Cancer Research (Jan 2015)

“ENDS may be beneficial if they reduce smoking rates or prevent or reduce the known adverse health effects of smoking. However, ENDS may also be harmful, particularly to youth, if they increase the likelihood that nonsmokers or formers smokers will use combustible tobacco products or if they discourage smokers from quitting. The American Association for Cancer Research (AACR) and the American Society of Clinical Oncology (ASCO) recognize the potential ENDS have to alter patterns of tobacco use and affect the public’s health; however, definitive data are lacking. AACR and ASCO recommend additional research on these devices, including assessing the health impacts of ENDS, understanding patterns of ENDS use, and determining what role ENDS have in cessation. Key policy recommendations include supporting federal, state, and local regulation of ENDS; requiring manufacturers to register with the FDA and report all product ingredients, requiring childproof caps on ENDS liquids, and including warning labels on products and their advertisements; prohibiting youth-oriented marketing and sales; prohibiting child-friendly ENDS flavors; and prohibiting ENDS use in places where cigarette smoking is prohibited.”

American College of Obstetricians and Gynecologists (May 2017)

• Exhaled ENDS vapor is not harmless water vapor—it has been shown to contain chemicals that cause cancer, can cause harm to unborn babies, and is a source of indoor air pollution. ENDS are promoted as a way to smoke where smoking is prohibited. However, state and local officials are incorporating ENDS use into existing smoke-free air regulations to protect health.
• Some people use ENDS as a way to quit smoking combustible cigarettes, but current evidence is insufficient to recommend ENDS for tobacco cessation in adults, and some people use both devices due to the addictive nature of nicotine.

ENDS are a health hazard

• ENDS companies can legally promote these products by using techniques that cigarette companies have not been able to use since the 1998 Master Settlement Agreement, including television and radio ads, billboards, outdoor signage, and sponsorships.
• ENDS and ENDS solutions are available in many flavors (bubble gum, chocolate, peppermint, etc.) that appeal to youth. Flavors, design, and marketing renormalize and glamorize smoking

National Academies of Science, Engineering and Medicine (Jan 2018)

Selected conclusions:

Conclusion 3-1. There is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels.

Conclusion 4-1. There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated.

Conclusion 4-2. There is substantial evidence that nicotine intake from e-cigarette devices among experienced adult e-cigarette users can be comparable to that from combustible tobacco cigarettes.

Conclusion 5-1. There is conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances.

Conclusion 5-2. There is conclusive evidence that, other than nicotine, the number, quantity, and characteristics of potentially toxic substances emitted from e-cigarettes are highly variable and depend on product characteristics (including device and e-liquid characteristics) and how the device is operated.

Conclusion 7-1. There is substantial evidence that e-cigarette aerosols can induce acute endothelial cell dysfunction, although the long-term consequences and outcomes on these parameters with long-term exposure to e-cigarette aerosol are uncertain.

Conclusion 7-2. There is substantial evidence that components of e-cigarette aerosols can promote formation of reactive oxygen species/oxidative stress. Although this supports the biological plausibility of tissue injury and disease from long-term exposure to e-cigarette aerosols, generation of reactive oxygen species and oxidative stress induction is generally lower from e-cigarettes than from combustible tobacco cigarette smoke.

Conclusion 8-1. There is substantial evidence that e-cigarette use results in symptoms of dependence on e-cigarettes.

Conclusion 10-1. There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans. This holds true for e-cigarette use compared with use of combustible tobacco cigarettes and e-cigarette use compared with no use of tobacco products.

Conclusion 10-2. There is limited evidence from in vivo animal studies using intermediate biomarkers of cancer to support the hypothesis that long-term e-cigarette use could increase the risk of cancer; there is no available evidence from adequate long-term animal bioassays of e-cigarette aerosol exposures to inform cancer risk.

Conclusion 10-4. There is substantial evidence that some chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) are capable of causing DNA damage and mutagenesis. This supports the biological plausibility that long-term exposure to e-cigarette aerosols could increase risk of cancer and adverse reproductive outcomes. Whether or not the levels of exposure are high enough to contribute to human carcinogenesis remains to be determined.

Conclusion 11-1. There is no available evidence whether or not e-cigarettes cause respiratory diseases in humans.

Conclusion 16-1. There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.

Conclusion 17-1. Overall, there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation.

National Alliance for Hispanic Health (April 2019)

“E-cigarettes are addicting a new generation of smokers and online retail sales are a driving force. We applaud the bipartisan introduction today of the Preventing Online Sales of E-Cigarettes to Children Act to close the online door to underage sales and protect the health of our children … E-cigarette sales are driving a youth tobacco tipping point.  It is time for us to protect youth and give parents the tools they need to ensure their children cannot easily evade age restrictions on purchase of e-cigarettes”

Prevention Institute (Aug 2016)

“Big Tobacco and its allies have been trying to obscure the emerging science on the dangers e-cigarettes pose to public health. But claims that “vaping” is a healthier alternative to cigarettes, instead of a gateway, were disproven by a recent American Journal of Public Health study that found smokers who have used e-cigarettes are less likely to cut back on cigarettes in the future than smokers who haven’t used them.”

U.S. Preventative Services Task Force (Sept 2015)

“The evidence on the benefits versus harms of e-cigarettes is still emerging. There are significant population health concerns, and it is unclear if the potential benefit to the individual adult smoker interested in quitting outweighs the potential harms of attractiveness to youth, including a gateway to cigarette smoking and changing norms around vaping and smoking
The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) for tobacco cessation in adults, including pregnant women.”

US Surgeon General (2016)

“The use of products containing nicotine poses dangers to youth, pregnant women, and fetuses. The use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe.. E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful constituents, including nicotine. Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain. 

U.S. Food and Drug Administration

Statement from FDA Commissioner Scott Gottlieb, M.D., on proposed new steps to protect youth by preventing access to flavored tobacco products and banning menthol in cigarettes

“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids.”

“Today, I’m announcing proposals to help reverse these trends, with the unwavering support of HHS Secretary Alex Azar, who shares my deep commitment to protecting the health of our nation’s children. Today, we advance our efforts to combat youth access and appeal with a policy framework that firmly and directly addresses the core of the epidemic – flavors.

The data show that kids using e-cigarettes are going to be more likely to try combustible cigarettes later. This is a large pool of future risk.”

“These increases must stop. And the bottom line is this: I will not allow a generation of children to become addicted to nicotine through e-cigarettes. We won’t let this pool of kids, a pool of future potential smokers, of future disease and death, to continue to build. We’ll take whatever action is necessary to stop these trends from continuing.”

Understanding the Health Impact and Dangers of Smoke and ‘Vapor’

“While we’re still learning about the long-term potential benefits and health risks of e-cigarettes and related products, existing scientific research offers some clear evidence that several of the dangerous chemicals in tobacco smoke are also present in the aerosol of some e-cigarette products. And this is concerning because of the very technology that distinguishes e-cigarettes — their delivery system that feeds aerosol into the body. We know that aerosol exposure is a major health concern due to the ability of aerosol particles to penetrate deeply into the respiratory system. E-cigarette aerosols can enter the lungs and small airways in various ways, which may depend on a number of factors, including nicotine content and the type of e-cigarette. That means some of the toxic chemicals and other substances contained in e-cig aerosols have the potential to go deep into the lungs and may pose risk for diseases not usually seen in smokers.

This is why we’ve been so concerned about youth use of these products. It’s not just the addiction to nicotine, and the potential for kids who become addicted to nicotine from e-cigarettes to eventually transition to regular combustible cigarettes. It’s also the direct risks posed by the e-cigarettes themselves.

This isn’t idle speculation. We know the aerosol produced by some e-cigarettes can contain high amounts of some toxic substances.”

“Still another potential danger from certain types of e-cigarette designs can relate to the metal coil elements that heat and cool the product.”

“The mounting research on the physical impacts of aerosol produced by e-cigarettes provides a strong basis for concern. This is especially true when it comes to use of these products by children. But there remains a great deal to learn.”

“We’re especially concerned by evidence from animal studies that the vapor in e-cigarettes can cause changes to tissue in the airways that can induce cancer or be a precursor to cancer. We have initiated a comprehensive research plan to fully evaluate these risks, and we will report our results publicly.”

“The FDA has made a strong commitment and taken a number of actions to address the addictiveness posed by nicotine in cigarettes. However, there are now new concerns about the dangers from aerosols inhaled by users of e-cigarettes. We see potential opportunity from the ENDS products for currently addicted adult smokers to help them quit smoking. But we also see risk, especially when it comes to youth use of these products.”

“…we also must consider the risks of use by youth and others not already addicted to cigarettes. Whether it’s traditional cigarettes or e-cigarettes, the FDA will remain especially firm in preventing kids from using and becoming addicted to tobacco products.”

US National Institute on Drug Abuse (2015)

“Some people believe e-cigarettes may help lower nicotine cravings in those who are trying to quit smoking. However, e-cigarettes are not an FDA-approved quit aid, and there is no conclusive scientific evidence on the effectiveness of e-cigarettes for long-term smoking cessation… E-cigarettes haven’t been thoroughly evaluated in scientific studies. For now, not enough data exists on the safety of e-cigarettes, how the health effects compare to traditional cigarettes, and if they are helpful for people trying to quit smoking. “

Europe

European Public Health Association (2018)

“The health risks associated with e-cigarettes remain uncertain but they cannot be considered safe. What is certain is that statements that they are some percentage safer than conventional cigarettes are so far unjustified… Overall, e-cigarettes may help some smokers quit but, for most, e-cigarettes depress quitting…. The net effect of making e-cigarettes widely available, at population level, seems likely to be an increase in sole and dual use of e-cigarettes and sole smoking unless there is very stringent regulation.”

European Respiratory Society: Task Force report  (2018)

“ECIG aerosol contains potentially toxic chemicals. As compared to conventional cigarettes, these are fewer and generally in lower concentrations. Second-hand exposures to ECIG chemicals may represent a potential risk, especially to vulnerable populations. There is not enough scientific evidence to support ECIGs as an aid to smoking cessation due to a lack of controlled trials, including those that compare ECIGs with licenced stop-smoking treatments. So far, there are conflicting data that use of ECIGs results in a renormalisation of smoking behaviour or for the gateway hypothesis. Experiments in cell cultures and animal studies show that ECIGs can have multiple negative effects. The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term. Based on current knowledge, negative health effects cannot be ruled out.”

plus statement in May 2019 “”There is also a lack of evidence to support the claims that e-cigarettes are more effective than established smoking cessation medications or nicotine replacement therapies, but the few independent studies that have been published indicate that e-cig and heated tobacco device use undermines quit attempts outside of a clinical setting, and show that most people use alternative nicotine delivery products alongside conventional cigarettes, rather than as a replacement.”

OTHER NATIONS

Indian Council on Medical Research (2019)

“Based on the currently available scientific data from multiple streams of research, the Council recommends complete prohibition on ENDS or e-cigarettes in India in the greater interest of protecting public health, in accordance with the precautionary principle preventing public harm from a noxious agent, considering the following facts and circumstances:

• ENDS or e-cigarettes contain nicotine solution, which is highly addictive, and also contain other ingredients as flavouring agents and vapourizers, which are also harmful for health.

• Use of ENDS or e-cigarettes has documented adverse effects on humans which include DNA damage; carcinogenesis; cellular, molecular and immunological toxicity; respiratory, cardiovascular and neurological disorders and adverse impact on foetal development and pregnancy.

• The magnitude of potential short-term and long-term health risks to the users still remains undetermined at the population level since the products are recent and come in diverse forms.

• Whereas, the degree to which, if at all, the ENDS or e-cigarettes benefit as tobacco cessation aides is not firmly established, evidence suggests that there is a risk of dual use to some extent and initiation to tobacco addiction to non-smokers. Hence, on the balance these products have a net negative impact on public health.

• Use of ENDS can open a gateway for new tobacco addiction which is a potential threat to the country’s tobacco control laws and on-going tobacco control programmes.

• The rapidly increasing trend of use of ENDS or e-cigarettes by young persons, in countries where it was introduced, underscores a potential threat to public health.”

Acknowledgements: Quit Victoria and Campaign for Tobacco Free Kids, Washington DC.