Just when you thought tobacco was out, e-cigarettes brought it back in.

The re-emergence of smoking, now with electronic vaporizing e-cigarettes, has caught regulators flat-footed. Public health groups have scrambled to respond to proponents’ claims that the high-tech cigarettes are safer for smokers and don’t produce secondhand smoke.

The American Heart Association (AHA) is hoping to bring some clarity to the issue with a detailed account of the science on e-cigarettes and recommendations about how they should be regulated.

Cigarette smoking accounts for one in every five deaths in the United States. While smoking has fallen off dramatically since the mid-1970s,  of Americans still smoke.

E-cigarettes offer nicotine, the addictive compound in cigarettes, in a vaporized form. The devices, sold in smoke shops, drug stores, and online, hold a small amount of nicotine solution and heat it using a small coil as the user inhales.

Their use in cities has risen dramatically, particularly among young, white, and middle-class tobacco users. According to one prediction cited in the AHA study, sales margins may reach $10 billion by 2017, surpassing those of conventional cigarettes. Major tobacco companies are getting into the business and may control 75 percent of the market within a decade.

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Tobacco or Not Tobacco?

The AHA calls for e-cigarettes to be categorized as tobacco products, which would allow the U.S. Food and Drug Administration to regulate them as it does cigarettes and smokeless tobacco.

“We believe strongly that this is a tobacco product,” said Aruni Bhatnagar, a professor of environmental cardiology at the University of Louisville and the lead author of the AHA paper, published today in its journal Circulation.

It may seem obvious, but the FDA only gained the right to regulate tobacco products in 2009. And though nicotine is the addictive component of tobacco, it’s also found in lesser concentrations in related plants, including tomatoes and eggplants. The FDA’s effort to regulate e-cigarettes as drugs was shot down in a 2010 court decision. But it is continuing to try to regulate them as tobacco products.

The law specifically lists what counts as tobacco products for the FDA's purpose. But it allows the agency to add other products that meet “the statutory definition of a tobacco product, which is ‘made or derived from tobacco’” after going through a rulemaking process, said Jennifer Haliski, an FDA spokeswoman.

“That process is happening now,” Haliski said.

E-cigarette advocates argue that their products, also called “vapes,” are safer than conventional cigarettes and give many smokers a healthier alternative or even a pathway to quitting.

The AHA paper says that the evidence to support these claims is weak.

“Some comparisons have shown that they may be less toxic, but if you read into it, first, most of these are small studies and, secondly, there’s a complete absence of long-term studies. So the statement that we know from scientific evidence that they are safer than cigarettes is not true,” Bhatnagar said.

In fact, many smokers who take up vaping continue to smoke cigarettes as well.  

“They may use e-cigarettes to bypass smoke-free laws and that will just fuel nicotine addiction and perhaps create a generation of smokers who are more addicted,” Bhatnagar said.

Nevertheless, the AHA recommendations leave the door open for the use of e-cigarettes for smokers with an active quit date in mind and who have tried and failed to quit using more conventional methods. 

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What’s in a Vape?

Nicotine is the most addictive but not the most dangerous chemical in cigarettes, which contain upwards of 200 additional chemicals.

Though e-cigarette advocates present their nicotine fluids as a purer alternative, in fact, little is known about what’s in them. 

Even the strength of nicotine varies widely, and is generally not identified on the packaging. The AHA calls for printed information on the strength of the nicotine solution, as well any other chemicals the liquid might contain.

The study sites evidence that some e-cigarette liquids contain cancer-causing tobacco alkaloids, metals (sometimes from the heating coils), and other volatile and toxic chemicals.

The FDA has issued warning letters to makers of e-cigarette fluids that were found to contain the weight-loss drug rimonabant (Zimulti) and the erectile dysfunction medication tadalafil (Cialis).

E-cigarette makers have also angered public health advocates by adding flavors, including bubble gum, to the vaporizer fluids, seeming to appeal to children. Nicotine has been linked to neurological problems in young tobacco users.

The AHA is calling for a national ban on e-cigarette sales to minors. Currently, some states have such bans in place, but they are ineffective because many young people buy e-cigarettes online.

E-cigarette defenders also assert that vaporizing nicotine does not produce secondhand smoke, which kills more than 400,000 Americans every year. But that’s only partially true, according to the AHA report.

Studies that put vape-users in a small chamber and then measured the chemical make-up of the air in the chamber found chemicals including formaldehyde, acetaldehyde, and acetic acid.

The concentration of these chemicals was just a fraction of what one would find in secondhand smoke from a cigarette.