Positions of medical organizations on electronic cigarettes

Last updated

The scientific community in the United States and Europe are primarily concerned with the possible effect of electronic cigarette use on public health. [1] There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to control tobacco, [2] and serve as a gateway for smoking among youth. [3] The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for quitting smoking is unclear. [4] Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco. [3] There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things. [5]

Contents

Medical organizations differ in their views about the health implications of vaping [6] and avoid releasing statements about the relative toxicity of electronic cigarettes because of the many different device types, liquid formulations, and new devices that come onto the market. [7] Some healthcare groups and policy makers have hesitated to recommend e-cigarettes with nicotine for quitting smoking, despite some evidence of effectiveness (when compared to Nicotine Replacement Therapy or e-cigarettes without nicotine) and safety. [7] Reasons for hesitancy include challenges ensuring that quality control measures on the devices and liquids are met, unknown second hand vapour inhalation effects, uncertainty about EC use leading to the initiation of smoking or effects on people new to smoking who develop nicotine dependence, unknown long-term effects of electronic cigarette use on human health, uncertainty about the effects of ECs on smoking regulations and smoke free legislation measures, and uncertainty about involvement of the tobacco industry. [7]

Some have advocated bans on e-cigarette sales and others have suggested that e-cigarettes may be regulated as tobacco products but with less nicotine content or be regulated as a medicinal product. [8] A 2016 World Health Organization (WHO) report found that the scientific evidence for the effectiveness of vaping for quitting smoking is "scant and of low certainty". [9] Healthcare organizations in the United Kingdom in 2015 have encouraged smokers to try e-cigarettes to help them quit smoking and also encouraged e-cigarette users to quit smoking tobacco entirely. [10] In 2016, the US Food and Drug Administration (FDA) stated that "Although ENDS [electronic nicotine delivery systems] may potentially provide cessation benefits to individual smokers, no ENDS have been approved as effective cessation aids." [11] In 2019 the European Respiratory Society stated that "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." [12] Following hundreds of possible cases of severe lung illness and five confirmed deaths associated with vaping in the US, the Centers for Disease Control and Prevention stated on September 6, 2019, that people should consider not using vaping products while their investigation is ongoing. [13]

International

In August 2016, a report produced by the World Health Organization (WHO) for the Conference of the Parties to the WHO Framework Convention on Tobacco Control, found "there is not enough research to quantify the relative risk of ENDS/ENNDS over combustible products. Therefore, no specific figure about how much 'safer' the use of these products is compared to smoking can be given any scientific credibility at this time." [9]

In July 2014, a WHO report found there was not enough evidence to determine if electronic cigarettes can help people quit smoking and made various recommendations as to a suitable regulatory framework for them. [14] Smokers should be encouraged to use approved methods for help with quitting, but the same report also noted that experts indicate that e-cigarettes may have a role in helping some smokers who have failed to quit by other means. [14] The report stated that "Smokers will obtain the maximum health benefit if they completely quit both tobacco and nicotine use." [14]

In August 2014, the Forum of International Respiratory Societies, which represents multiple pulmonary associated medical associations in the United States, Latin America, Africa, Europe, and Asia, released a statement in which they argued that e-cigarettes have not been demonstrated to be safe and their benefits as a smoking cessation tool or in harm reduction has not been adequately studied. [15] They recommended banning their use, or regulation as medicines or tobacco products if not banned, until adequate studies are performed. [15]

In May 2018, the Forum of International Respiratory Societies released a position statement, stating "ENDS are devices that deliver aerosols of nicotine and other volatile chemicals to the lung. Their use has rapidly escalated among youths and they are now the most commonly used tobacco product among adolescents. Initiation of electronic cigarette use is strongly associated with the subsequent initiation of combustible tobacco product use among adolescents." [16]

In January 2014, the International Union Against Tuberculosis and Lung Disease released a statement asserting that the benefits and safety of e-cigarettes have not been scientifically proven. [17] The statement highlighted concerns with regards to "re-normalization" of smoking behavior and exposure of third parties to possibly dangerous emissions from e-cigarettes, and strongly supported regulation of electronic cigarettes, preferably as medicines. [17]

The World Lung Foundation (now known as Vital Strategies) applauded the 2014 WHO report's recommendation for tighter regulation of e-cigarettes due to concerns about the safety of e-cigarettes and the possible increased nicotine or tobacco addiction among youth. [3]

In October 2012, the World Medical Association released a statement which stated, "Due to the lack of rigorous chemical and animal studies, as well as clinical trials on commercially available e-cigarettes, neither their value as therapeutic aids for smoking cessation nor their safety as cigarette replacements is established. [18] Lack of product testing does not permit the conclusion that e-cigarettes do not produce any harmful products even if they produce fewer dangerous substances than conventional cigarettes." [18]

Australia

The Therapeutic Goods Administration (TGA) of Australia stated in 2014 that "the quality and safety of electronic cigarettes is not known" due to the lack of studies, unlike conventional nicotine replacement therapies, and lists possible risks involved with buying or using electronic cigarettes. [19] They also state, "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." [19]

A 2014 practice guideline by NPS MedicineWise states, "While use of e-cigarettes may be safer than smoking tobacco, so far there is limited evidence to support their effectiveness as aids in smoking cessation. There are also safety issues to consider and the long-term effects are unknown." [20] This guideline recommends physicians steer patients away from e-cigarettes to "more established" methods of smoking cessation until safety and efficacy are established. [20]

The Cancer Council Australia and Heart Foundation released a joint position statement in 2014 that stated, "The limited evidence available points to a risk that widespread electronic cigarette use could undo the decades of public policy work in Australia that has reduced the appeal of cigarette use in children" and the "short and long term health effects of electronic cigarette use remain unknown." [21] They also consider claims that e-cigarettes can help quit smoking as "unsubstantiated" and urge "extreme caution on electronic cigarettes" while urging significant regulations of both nicotinic and non-nicotinic electronic cigarettes. [21]

Following 7 reported deaths in the US associated with vaping-induced lung illness, the Australian Medical Association stated on September 18, 2019, that they reiterate a precautionary approach for the use of vaping products. [22]

In January 2020 the Royal Australian College of General Practitioners updated their advice on smoking cessation, stating that "for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, but who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine-containing e-cigarettes may be a reasonable intervention to recommend." [23]

Canada

Health Canada states in relation to the Tobacco and Vaping Products Act which became law on May 23, 2018, that "vaping is less harmful than smoking. [24] Many of the toxic and cancer-causing chemicals in tobacco and the tobacco smoke form when tobacco is burned." [24] They further state that "vaping products and e-cigarettes deliver nicotine in a less harmful way than smoking, and may reduce health risks for smokers". [24]

The Canadian Cancer Society has concluded, e-cigarettes "have not been scientifically proven to help people quit" smoking tobacco. [25]

The Canadian Heart and Stroke Foundation has stated, "While early studies show some potential benefits, the effectiveness of e-cigarettes with nicotine as a smoking cessation device is not fully conclusive," and expressed concerns about the lack of long-term studies with regard to health effects to the user as well as second-hand exposure. [2] They also note public health officials' concerns about renormalizing smoking behavior undermining current tobacco control as well as being a gateway for nicotine addiction and tobacco use disorder. [2]

China

About 1 adult in 4 smokes, but only 1 in 200 vape. [26] Tobacco-flavor is the only flavor allowed [27] and ecigs cannot be sold online. [28] 2.7 million people die each year due to smoking. [26]

New Zealand

In 2014, the Ministry of Health of New Zealand has reviewed the evidence around e-cigarettes and has stated, "The long-term health risks associated with vaping products are still unknown but evidence suggests that they are much lower than the risks associated with tobacco smoking. As such it is expected that health risks will reduce significantly for smokers who switch to vaping." and recommends "encourages smokers who want to use vaping products to quit smoking to seek the support of local stop smoking services". [29] In 2016 they stated, "There is a lack of clarity about long-term health risks to users and the potential adverse effects on non-users exposed to e-cigarette vapour."

In 2020, the Ministry of Health of New Zealand issued a new position statement on nicotine vaping: “The Ministry considers vaping products could disrupt inequities and contribute to Smokefree 2025. The evidence on vaping products indicates they carry much less risk than smoking cigarettes but are not risk free. Evidence is growing that vaping can help people to quit smoking. There is no international evidence that vaping products are undermining the long-term decline in cigarette smoking among adults and youth, and may in fact be contributing to it.”

The Cancer Society of New Zealand released a position statement which states, "There is growing evidence that e-cigarettes containing nicotine assist adult smokers to quit smoking tobacco. E-cigarettes pose fewer risks than tobacco and reduce the user’s exposure to numerous toxicants present in tobacco." and that "Adult smokers have access to quality-controlled e-cigarettes/e-liquid and tobacco smoking cessation advice. [30]


Philippines

The Food and Drug Administration of the Philippines released a statement saying that there has been little evidence published about the health effects of electronic cigarettes, including whether they help quit smoking. [31] The statement concluded that the available evidence does not support those who advocate for their use either as tools to help quit smoking or for harm reduction. [31]

The Philippine Medical Association has also taken a strong position against the use of electronic cigarettes, citing safety concerns. [32]

Europe

In 2019 the European Respiratory Society stated that "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." [12] However, in 2020 the World Health Organization Regional Office for Europe issued a report stating, "There is conclusive evidence that: Completely substituting electronic nicotine and non-nicotine delivery systems for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.” [33]

France

In 2019, the Académie Nationale de Médecine (French National Academy of Medicine) issued this public statement (translated to English): “It is established that the vaporette is less dangerous than the cigarette… It is therefore preferable for a smoker to vape. Since 2016, the High Authority for Health (HAS) considers it ‘as an aid to stop or reduce the consumption of tobacco by smokers.’ Santé Publique France indicates that at least 700,000 [French] smokers have quit using electronic cigarettes. ...Smokers who were about to switch to vaporizing instead of tobacco should not hesitate...” But in 2022, French health body le Haut Conseil de la santé publique (HCSP) changed its advice, and now says health professionals should not recommend e-cigarettes for quitting, as there is not enough information on risks and benefits.

Germany

The German Cancer Research Center in Germany released a report in 2013 stating that e-cigarettes cannot be considered safe, in part due to technical flaws that have been found as well as unreliable information about product quality, including information provided by manufacturers. [34] This report concluded the fluids and aerosols in e-cigarettes can contain dangerous substances and can cause short term airway irritation and may be harmful in long term use, and the effects on second hand exposure causing harm cannot be ruled out. [34] The report also concluded that the e-cigarettes, whether it contains nicotine or not, can alleviate cravings and withdrawal symptoms, but their ability to help quit smoking has not been proven. [34]

Spain

The Spanish Society of Pneumonology and Thoracic Surgery (SEPAR) released a position statement which states that the substances found in aerosol from e-cigarettes have not been demonstrated to be safe, and a number of chemicals which are carcinogens and can damage the lung have been found, though usually in concentrations smaller than conventional cigarettes. [35] Studies done to date have been small in size and have had significant methodological flaws, making drawing any definitive conclusions about their ability to aid in smoking cessation impossible. [35] The report concluded that "indiscriminate use" of e-cigarettes is a public health risk and they may encourage young people to start smoking, and therefore advocate regulation of e-cigarettes as a medicine and encourage smoking cessation through other more established means. [35]

United Kingdom

A 2018 Public Health England report reiterated the approximation that e-cigarettes are 95% less harmful than smoking. [36]

United States

Government agencies

Following five confirmed deaths in the US, on September 6, 2019, the Centers for Disease Control and Prevention stated that while this investigation is ongoing, people should consider not using e-cigarette products. [13] In 2016, the US Food and Drug Administration (FDA) stated that "Although ENDS [electronic nicotine delivery systems] may potentially provide cessation benefits to individual smokers, no ENDS have been approved as effective cessation aids." [11] They also stated that "Although ENDS likely do not deliver the same level of toxicants as cigarettes, studies show that there are dangers associated with ENDS use". [11]

Medical societies

On September 9, 2019, following an upsurge of reports of lung disease associated with vaping, the American Medical Association issued a statement saying "In light of increasing reports of e-cigarette-associated lung illnesses across the country, the AMA urges the public to avoid the use of e-cigarette products until health officials further investigate and understand the cause of these illnesses." [37] The next day the American Lung Association issued a warning, saying "E-cigarettes are not safe and can cause irreversible lung damage and lung disease. No one should use e-cigarettes or any other tobacco product. This message is even more urgent today following the increasing reports of vaping-related illnesses and deaths nationwide." [38] On November 19, 2019, the American Medical Association urged for a complete ban on all types of vaping products that are not approved by the US FDA as quitting smoking aids. [39]

References

  1. ↑ Gualano, Maria Rosaria; Passi, Stefano; Bert, Fabrizio; La Torre, Giuseppe; Scaioli, Giacomo; Siliquini, Roberta (2015). "Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies". Journal of Public Health. 37 (3): 488–497. doi: 10.1093/pubmed/fdu055 . ISSN   1741-3842. PMID   25108741.
  2. 1 2 3 "Heart and Stroke Foundation: E-cigarettes in Canada". Heart and Stroke Foundation. September 2014. Archived from the original on 2014-10-06.
  3. 1 2 3 "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. 26 August 2014. Archived from the original on March 30, 2018.
  4. ↑ Franck, Caroline; Filion, Kristian B.; Kimmelman, Jonathan; Grad, Roland; Eisenberg, Mark J. (2016). "Ethical considerations of e-cigarette use for tobacco harm reduction". Respiratory Research. 17 (1): 53. doi: 10.1186/s12931-016-0370-3 . ISSN   1465-993X. PMC   4869264 . PMID   27184265.
  5. ↑ Bullen, Chris; Knight-West, Oliver (2016). "E-cigarettes for the management of nicotine addiction". Substance Abuse and Rehabilitation. 7: 111–118. doi: 10.2147/SAR.S94264 . ISSN   1179-8467. PMC   4993405 . PMID   27574480.
  6. ↑ "FCA Policy briefing Electronic Nicotine Delivery Systems" (PDF). Framework Convention Alliance on Tobacco Control. 13–18 October 2014. Archived from the original (PDF) on 6 March 2016. Retrieved 26 August 2016.
  7. 1 2 3 Hartmann-Boyce, Jamie; McRobbie, Hayden; Butler, Ailsa R.; Lindson, Nicola; Bullen, Chris; Begh, Rachna; Theodoulou, Annika; Notley, Caitlin; Rigotti, Nancy A.; Turner, Tari; Fanshawe, Thomas R.; Hajek, Peter (2021-09-14). "Electronic cigarettes for smoking cessation". The Cochrane Database of Systematic Reviews. 9 (9): CD010216. doi:10.1002/14651858.CD010216.pub6. ISSN   1469-493X. PMC   8438601 . PMID   34519354.
  8. ↑ McRobbie, Hayden; Bullen, Chris; Hartmann-Boyce, Jamie; Hajek, Peter; McRobbie, Hayden (2014). "Electronic cigarettes for smoking cessation and reduction". The Cochrane Database of Systematic Reviews. 12 (12): CD010216. doi:10.1002/14651858.CD010216.pub2. hdl: 2292/27824 . PMID   25515689.
  9. 1 2 "Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS)" (PDF). World Health Organization. August 2016. pp. 1–11.
  10. ↑ "E-cigarettes: an emerging public health consensus". UK: Public Health England. 15 September 2015.
  11. 1 2 3 "Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products". Federal Register. 81 (90). US Food and Drug Administration: 28974–29106. 10 May 2016.
  12. 1 2 Bals, Robert; Boyd, Jeanette; Esposito, Susanna; Foronjy, Robert; Hiemstra, Pieter S.; Jiménez-Ruiz, Carlos A.; Katsaounou, Paraskevi; Lindberg, Anne; Metz, Carlos; Schober, Wolfgang; Spira, Avrum; Blasi, Francesco (2019). "Electronic cigarettes: a task force report from the European Respiratory Society". European Respiratory Journal. 53 (2): 1801151. doi: 10.1183/13993003.01151-2018 . ISSN   0903-1936. PMID   30464018.
  13. 1 2 "Outbreak of Lung Illness Associated with Using E-cigarette Products". Centers for Disease Control and Prevention. 6 September 2019.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  14. 1 2 3 "Electronic nicotine delivery systems" (PDF). World Health Organization. 21 July 2014. pp. 1–13.
  15. 1 2 "E-Cigarettes". Oncology Times. 36 (15): 49–50. August 2014. doi:10.1097/01.COT.0000453432.31465.77.
  16. ↑ Ferkol, Thomas W.; Farber, Harold J.; La Grutta, Stefania; Leone, Frank T.; Marshall, Henry M.; Neptune, Enid; Pisinger, Charlotta; Vanker, Aneesa; Wisotzky, Myra; Zabert, Gustavo E.; Schraufnagel, Dean E. (2018). "Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies". European Respiratory Journal. 51 (5): 1800278. doi: 10.1183/13993003.00278-2018 . ISSN   0903-1936. PMID   29848575.
  17. 1 2 Bam, T. S.; Bellew, W.; Berezhnova, I.; Jackson-Morris, A.; Jones, A.; Latif, E.; Molinari, M. A.; Quan, G.; Singh, R. J.; Wisotzky, M. (1 January 2014). "Position statement on electronic cigarettes or electronic nicotine delivery systems [Official statement]". The International Journal of Tuberculosis and Lung Disease. 18 (1): 5–7. doi:10.5588/ijtld.13.0815. PMID   24365545.
  18. 1 2 "WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems". World Medical Association. Archived from the original on 8 December 2015. Retrieved 6 November 2014.
  19. 1 2 "Electronic cigarettes". Therapeutic Goods Administration. Retrieved 6 November 2014.
  20. 1 2 "e-Cigarettes: a safe way to quit?". NPS MedicineWise. Archived from the original on 19 March 2017. Retrieved 6 November 2014.
  21. 1 2 "Position Statement Electronic Cigarettes". Cancer Council Australia, Heart Foundation of Australia. 2014.
  22. ↑ "AMA Backs Strong Response to Vaping Deaths". Australian Medical Association. 18 September 2019.
  23. ↑ "RACGP endorses vaping for cessation". Royal Australian College of General Practitioners. January 28, 2020.
  24. 1 2 3 "Smoking, vaping and tobacco". Health Canada. 27 June 2018.
  25. ↑ "Ways to quit". Canadian Cancer Society. Archived from the original on 8 December 2015. Retrieved 6 November 2014.
  26. 1 2 "Smoking, vaping, HTP, NRT and snus in China". Global State of Tobacco Harm Reduction. Retrieved 2025-07-09.
  27. ↑ Wang, Zicheng; Xu, Xingchen; Laestadius, Linnea; Wang, Yang (2025-01-01). "Understanding stakeholder responses to the electronic cigarette flavor ban in China: A news media analysis". Public Health. 238: 303–309. doi:10.1016/j.puhe.2024.12.003. ISSN   0033-3506. PMID   39721111.
  28. ↑ Deng, Hui; Fang, Ling; Zhang, Lingyun; Wen, Sisi; Zhang, Shuai; Wang, Fan; Zheng, Pinpin (2024-09-14). "An observational study of the marketing practice of e-cigarette specialty stores in two large cities in China: Is there potential to normalize the use of e-cigarettes?". Tobacco Induced Diseases. 22 (September): 1–12. doi:10.18332/tid/191840. ISSN   1617-9625. PMC   11401606 . PMID   39280934. Archived from the original on 2025-06-18.
  29. ↑ "Electronic Nicotine Delivery Systems (ENDS), including E-cigarettes". New Zealand Ministry of Health. 2014. Archived from the original on 2015-05-11.
  30. ↑ "Position Statement on Electronic Cigarettes" (PDF). Cancer Society of New Zealand. June 2011. Archived from the original on 7 November 2014.
  31. 1 2 "Consumer Information on Electronic Cigarettes" (PDF). Food and Drug Administration of the Philippines. Archived from the original (PDF) on 28 December 2013. Retrieved 10 November 2014.
  32. ↑ Uy, Jocelyn (July 19, 2013). "Medical association urges local gov'ts to ban e-cigarettes". Philippine Daily Inquirer.
  33. ↑ "ELECTRONIC NICOTINE AND NON-NICOTINE DELIVERY SYSTEMS: A BRIEF" (PDF).
  34. 1 2 3 "Electronic Cigarettes – An Overview" (PDF). German Cancer Research Center. 2013. Retrieved 18 November 2014.
  35. 1 2 3 Jimenez Ruiz, CA; Solano Reina, S; de Granda Orive, JI; Signes-Costa Minaya, J; de Higes Martinez, E; Riesco Miranda, JA; Altet Gómez, N; Lorza Blasco, JJ; Barrueco Ferrero, M; de Lucas Ramos, P (August 2014). "The electronic cigarette. Official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes". Archivos de Bronconeumologia. 50 (8): 362–7. doi:10.1016/j.arbres.2014.02.006. PMID   24684764.
  36. ↑ McNeill, A; Brose, LS; Calder, R; Bauld, L; Robson, D (February 2018). "Evidence review of e-cigarettes and heated tobacco products 2018" (PDF). UK: Public Health England. p. 175.
  37. ↑ Harris, Patrice A. (9 September 2019). "AMA urges public to avoid e-cigarette use amid lung illness outbreak". American Medical Association.
  38. ↑ Wimmer, Harold (September 10, 2019). "American Lung Association: Do Not Use E-Cigarettes". American Lung Association. Retrieved 11 September 2019.
  39. ↑ "AMA calls for total ban on all vaping products not approved by FDA". American Medical Association. 19 November 2019.
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