Positions of medical organizations on electronic cigarettes

The scientific community in 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]

Medical organizations differ in their views about the health implications of vaping.[6] There is general agreement that e-cigarettes expose users to fewer toxicants than tobacco cigarettes.[7] Some healthcare groups and policy makers have hesitated to recommend e-cigarettes for quitting smoking, because of limited evidence of effectiveness and safety.[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 but they also encouraged users to quit 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]

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.[12] 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.[12] The report stated that "Smokers will obtain the maximum health benefit if they completely quit both tobacco and nicotine use."[12]

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.[13] They recommended banning their use, or regulation as medicines or tobacco products if not banned, until adequate studies are performed.[13]

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.[14] 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.[14]

The World Lung Foundation 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.[15] 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."[15]

Australia

The Therapeutic Goods Administration (TGA) of Australia has stated 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.[16] 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."[16]

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."[17] This guideline recommends physicians steer patients away from e-cigarettes to "more established" methods of smoking cessation until safety and efficacy are established.[17]

The Cancer Council Australia and Heart Foundation released a joint position statement 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."[18] 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.[18]

Canada

Health Canada concluded in March 2013 that, "To date, no electronic cigarettes with nicotine and/or health claims have been authorized by Health Canada and their safety, quality, and efficacy remain unknown" and "Health Canada advises Canadians not to purchase or use electronic cigarettes as these products may pose health risks."[19]

The Canadian Cancer Society has concluded, e-cigarettes "have not been scientifically proven to help people quit" smoking tobacco.[20]

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 abuse.[2]

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.[21] 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.[21] 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.[21]

New Zealand

The Ministry of Health of New Zealand has stated, "There is not enough evidence to be able to recommend e-cigarettes as an aid to quit smoking" and recommends more established treatments for smoking cessation.[22] They also point interested readers to the 2014 WHO statement for further information.[22]

The Cancer Society of New Zealand released a position statement which states, "Currently, there is limited evidence of the safety of e-cigarettes or their suitability as a smoking cessation aid" and "Before they are widely promoted, evidence is needed to ensure that e-cigarettes are a safe harm reduction alternative to tobacco smoking, that they are a safe and effective cessation aid, that they don’t undermine motivation to quit, and that they don’t act as a gateway to nicotine addiction for young people."[23]

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.[24] 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.[24]

The Philippine Medical Association has also taken a strong position against the use of electronic cigarettes, citing safety concerns.[25]

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.[26] 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.[26] 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.[26]

United Kingdom

In a 2015 joint statement, Public Health England and twelve other UK medical bodies concluded "e-cigarettes are significantly less harmful than smoking."[27] A 2015 Public Health England report stated that e-cigarettes are estimated to be 95% less harmful than smoking.[28] In a policy statement released with the report, Public Health England said that "PHE looks forward to the arrival on the market of a choice of medicinally regulated products that can be made available to smokers by the NHS on prescription."[29]

In 2015 the English National Health Service advice page on smoking said "E-cigarettes are not risk free, but on current evidence they carry a fraction of the risk of smoked tobacco.[30] As well as nicotine, e-cigarette liquid and vapour can contain toxic substances, although these are either at lower levels than seen in cigarette smoke or at levels not associated with health risk.[30] The current best estimate is that e-cigarette use carries only around 5% of the risk of smoking.[30] E-cigarettes are still fairly new and we won’t have a full picture on their safety until they have been in use for many years, so it will be important to continue to monitor the evidence as it develops."[30] The UK National Health Service concluded in November 2014, "While e-cigarettes may be safer than conventional cigarettes, we don’t yet know the long-term effects of vaping on the body.[31] There are clinical trials in progress to test the quality, safety and effectiveness of e-cigarettes, but until these are complete, the government can’t give any advice on them or recommend their use."[31] In December 2015, the BBC reported that five Scottish NHS boards were considering reviewing their ban on e-cigarette use on hospital grounds, after 'new evidence showed they can help smokers quit'.[32]

In 2014 the UK's National Centre for Smoking Cessation and Training, which provides training and accreditation to NHS "stop smoking practitioners",[33] issued a new guideline downplaying concerns and stating that smoking cessation professionals should support e-cigarette users, though they remain unable to prescribe e-cigarettes.[34]

A 2015 policy statement by the UK's Faculty of Public Health recognizes that there are potential benefits from the use of e-cigarettes but raises concerns that their effectiveness is not yet proven, that e-cigarettes are less effective than nicotine replacement therapy, concerns regarding dual usage of e-cigarettes and tobacco, concerns regarding advertising and young people and finally concerns regarding e-cigarettes undermining "decades of lobbying by public health related organisations" that led to the "smoking ban and tobacco control legislation".[35]

The British Medical Association (BMA) reported in 2013 that there was a possibility for smoking cessation benefits, but had concerns that e-cigarettes are less regulated than nicotine replacement therapy (NRT), and that there was no peer reviewed evidence concerning their safety or efficacy.[36]

In May 2014, Cancer Research UK released a statement including, "Electronic cigarettes (e-cigarettes) are almost certainly much safer than tobacco cigarettes and may help smokers to cut down or quit smoking. We support the use of high quality e-cigarettes because we believe that they have significant potential to help smokers who aren't otherwise ready or able to quit smoking by providing them with much safer alternatives to smoked tobacco. It is important that regulation does not stifle the development of this market nor make accessing these products by smokers more difficult. However, the current safeguards are insufficient to ensure that these products are as safe as nicotine replacement therapy and to ensure that they are not marketed to non-smokers and children."[37]

A National Institute for Health and Care Excellence (NICE) guideline in 2013 recommended licensed nicotine replacement therapy as part of a program for harm reduction, but did not recommend e-cigarettes as they are unregulated.[38]

The Royal College of General Practitioners (RCGP) stated in 2016 that "although the long-term safety profile of EC use is still to be evaluated, it is accepted that vaping is an order of magnitude safer than conventional tobacco."[39] The RCGP recommended, among other things, that "Where a patient wants to quit smoking, and has not succeeded with other options, GPs [general practitioners] should recommend and support the use of ENDS."[39] In April 2016, the Royal College of Physicians released a statement recommending that e-cigarettes be offered to smokers of conventional cigarettes to encourage quitting, stating "in the interests of public health it is important to promote the use of e-cigarettes" as well as NRT and other non-tobacco nicotine products as a replacement to tobacco smoking.[40]

United States

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] In 2014, the FDA concluded, "E-cigarettes have not been fully studied, so consumers currently don’t know: the potential risks of e-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products.[41] Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death."[41]

In 2015, the United States Preventive Services Task Force concluded there is insufficient evidence to recommend e-cigarettes for smoking cessation, and recommended clinicians instead recommend more proven smoking cessation aids.[42]

In early 2015, Smokefree.gov, a website run by the Tobacco Control Research Branch of the National Cancer Institute to provide information to help quit smoking, did not recommend the use of e-cigarettes, saying "The bottom line is that we just don’t know enough about e-cigs, so we don’t recommend that you use them".[43]

In 2010, the American Medical Association called for e-cigarettes to be subject to the same FDA regulations as tobacco and nicotine products.[44] The Association extended this policy in 2014, and endorsed measures aimed at preventing marketing of e-cigarettes to minors.[44]

In August 2014, the American Heart Association released a policy statement in which they noted that "current evidence evaluating the efficacy of these products as a cessation aid is sparse, confined to 2 randomized controlled trials and 1 large cross-sectional study, anecdotal reports, and Internet-based surveys." The statement stated "there is not yet enough evidence for clinicians to counsel their patients who are using combustible tobacco products to use e-cigarettes as a primary cessation aid."[45] It also noted that "E-cigarettes either do not contain or have lower levels of several tobacco-derived harmful and potentially harmful constituents compared with cigarettes and smokeless tobacco. In comparison with NRTs, e-cigarette use has increased at an unprecedented rate, which presents an opportunity for harm reduction if smokers use them as substitutes for cigarettes.[45] However, although firm evidence is lacking, there are concerns that e-cigarette use and acceptance of e-cigarettes has the potential to renormalize smoking behavior, sustain dual use, and initiate or maintain nicotine addiction.[45] Their use also could serve as a gateway to reinitiation of smoking by ex-smokers. Unregulated e-cigarette use also has the potential to erode gains in smoking cessation and smoke-free laws."[45]

Another statement released that month by the American Lung Association argued that the FDA should begin its regulatory oversight of electronic cigarettes, because otherwise, "there is no way for the public health, medical community or consumers to know what chemicals are contained in e-cigarettes or what the short and long term health implications might be."[46]

The American Cancer Society concluded in early 2014, "Because the American Cancer Society doesn’t yet know whether e-cigarettes are safe and effective, we cannot recommend them to help people quit smoking. There are proven methods available to help people quit, including pure forms of inhalable nicotine as well as nasal sprays, gums, and patches."[47]

The US National Association of County and City Health Officials stated in 2012, "Currently, little scientific evidence exists to show that e-cigarettes are effective cessation devices" and "Further research is needed on the health risks of e-cigarettes, but available evidence suggests harmful effects.[48] They recommend to local health departments to advocate for regulation as a tobacco product to the extent allowable by law.[48]

The American Diabetes Association states "e-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation."[49]

In 2015, the American Association for Cancer Research and the American Society of Clinical Oncology released a statement noting that further research was needed regarding the regulation of electronic cigarettes.[50] The statement also called on the FDA Center for Tobacco Products to regulate all e-cigarettes that meet the definition of tobacco products.[50]

In October 2015, the American Academy of Pediatrics recommends against e-cigarettes for quitting smoking and stated among adolescents, e-cigarette use is related with reduced quitting smoking.[51] In 2015 the California Department of Public Health issued a report that found e-cigarettes expose users and bystanders to harmful chemicals, there is no scientific evidence they help smokers quit, they are being heavily marketed, and teen use is growing rapidly.[52]

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.
  3. 1 2 3 "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. 26 August 2014.
  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). doi:10.1186/s12931-016-0370-3. ISSN 1465-993X. PMC 4869264Freely accessible. 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 4993405Freely accessible. PMID 27574480.
  6. ↑ "FCA Policy briefing Electronic Nicotine Delivery Systems" (PDF). Framework Convention Alliance on Tobacco Control. 13–18 October 2014. Retrieved 2 March 2016.
  7. 1 2 Hartmann-Boyce, Jamie; McRobbie, Hayden; Bullen, Chris; Begh, Rachna; Stead, Lindsay F; Hajek, Peter; Hartmann-Boyce, Jamie (2016). "Electronic cigarettes for smoking cessation". doi:10.1002/14651858.CD010216.pub3. PMID 27622384.
  8. ↑ McRobbie, Hayden; Bullen, Chris; Hartmann-Boyce, Jamie; Hajek, Peter; McRobbie, Hayden (2014). "Electronic cigarettes for smoking cessation and reduction". The Cochrane Library. 12: CD010216. doi:10.1002/14651858.CD010216.pub2. PMID 25515689.
  9. 1 2 WHO (August 2016). "Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS)" (PDF). 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. US Food and Drug Administration. 81 (90): 28974–29106. 10 May 2016.
  12. 1 2 3 WHO. "Electronic nicotine delivery systems" (PDF). pp. 1–13. Retrieved 28 August 2014.
  13. 1 2 &NA; (August 2014). "E-Cigarettes". Oncology Times. 36 (15): 49–50. doi:10.1097/01.COT.0000453432.31465.77.
  14. 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.
  15. 1 2 "WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems". World Medical Association. Retrieved 6 November 2014.
  16. 1 2 "Electronic cigarettes". Therapeutic Goods Administration. Retrieved 6 November 2014.
  17. 1 2 "e-Cigarettes: a safe way to quit?". NPS MedicineWise. Retrieved 6 November 2014.
  18. 1 2 "Position Statement Electronic Cigarettes". Cancer Council Australia, Heart Foundation of Australia. 2014.
  19. ↑ "Nicotine addiction". Health Canada. Retrieved 6 November 2014.
  20. ↑ "Ways to quit". Canadian Cancer Society. Retrieved 6 November 2014.
  21. 1 2 3 "Electronic Cigarettes – An Overview" (PDF). German Cancer Research Center. 2013. Retrieved 18 November 2014.
  22. 1 2 "Electronic Nicotine Delivery Systems (ENDS), including E-cigarettes". New Zealand Ministry of Health. Retrieved 6 November 2014.
  23. ↑ "Position Statement on Electronic Cigarettes" (PDF). Cancer Society of New Zealand. Archived from the original (PDF) on 7 November 2014. Retrieved 6 November 2014.
  24. 1 2 "Consumer Information on Electronic Cigarettes" (PDF). Food and Drug Administration of the Philippines. Retrieved 10 November 2014.
  25. ↑ Uy, Jocelyn (July 19, 2013). "Medical association urges local gov'ts to ban e-cigarettes". Philippine Daily Inquirer.
  26. 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.
  27. ↑ "E-cigarettes: an emerging public health consensus". UK: Public Health England. 2015.
  28. ↑ McNeill, A, SC (2015). "E - cigarettes: an evidence update A report commissioned by Public Health England" (PDF). www.gov.uk. UK: Public Health England. p. 76. Retrieved 19 August 2015.
  29. ↑ "E - cigarettes: a new foundation for evidence - based policy and practice" (PDF). Public Health England. 19 August 2015. p. 5. Retrieved 22 August 2015.
  30. 1 2 3 4 "Electronic cigarettes". Smokefree NHS. Are e-cigarettes safe to use?. Retrieved 19 November 2015.
  31. 1 2 "Stop smoking treatments". UK National Health Service. Retrieved 6 November 2014.
  32. ↑ "Five Scottish health boards review e-cigarette policy". BBC Scotland. 25 December 2015.
  33. ↑ UCL Research Impact case study, "Evidence for best practice within NHS Stop Smoking Services"; NCSCT Final Report on their first 3 years to March 2012
  34. ↑ PDF, NCSCT briefing Electronic cigarettes, accessed 1 March 2015
  35. ↑ "People who want to quit smoking should consult their GP". Faculty of Public Health. Retrieved 7 March 2015.; Full statement, PDF
  36. ↑ "E-cigarettes not proven quitting aid, says BMA". British Medical Association. 30 January 2013. Retrieved 2 November 2014.
  37. ↑ "Cancer Research UK Briefing: Electronic Cigarettes" (PDF). Cancer Research UK. May 2014. Retrieved 5 November 2014.
  38. ↑ "Nicotine products can help people to cut down before quitting smoking". National Institute for Health and Care Excellence. 28 April 2016. Retrieved 10 November 2014.
  39. 1 2 "To vape or not to vape? The RCGP position on e-cigarettes". Royal College of General Practitioners. 2016.
  40. ↑ "Nicotine without smoke: Tobacco harm reduction". Royal College of Physicians. Retrieved 30 August 2016.
  41. 1 2 "Electronic Cigarettes (e-Cigarettes)". US Food and Drug Administration. Retrieved 6 November 2014.
  42. ↑ "Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions". United States Preventive Services Task Force. Retrieved 3 March 2016.
  43. ↑ "E-Cigarettes". Tobacco Control Research Branch of the National Cancer Institute. Retrieved 6 March 2015.
  44. 1 2 "AMA Strengthens Position on Regulation of Electronic Cigarettes". AMA. 10 June 2014. Retrieved 2 November 2014.
  45. 1 2 3 4 Bhatnagar, A.; Whitsel, L. P.; Ribisl, K. M.; Bullen, C.; Chaloupka, F.; Piano, M. R.; Robertson, R. M.; McAuley, T.; Goff, D.; Benowitz, N. (24 August 2014). "Electronic Cigarettes: A Policy Statement From the American Heart Association". Circulation. 130 (16): 1418–1436. doi:10.1161/CIR.0000000000000107. PMID 25156991.
  46. ↑ "American Lung Association Statement on E-Cigarettes". American Lung Association. 25 August 2014. Retrieved 2 November 2014.
  47. ↑ "What about electronic cigarettes? Aren't they safe?". American Cancer Society. Archived from the original on 23 September 2014. Retrieved 6 November 2014.
  48. 1 2 "Regulation of Electronic Cigarettes ("E-Cigarettes")" (PDF). National Association of County and City Health Officials. Archived from the original (PDF) on 5 July 2016.
  49. ↑ "Standards of Medical Care in Diabetes--2015: Summary of Revisions". Diabetes Care. 54 (38): S4. 2015. doi:10.2337/dc15-S003. PMID 25537706.
  50. 1 2 "AACR, ASCO, Two Leading U.S. Cancer Organizations, Call for Regulation of E-cigarettes and Other Electronic Nicotine Delivery Systems". AACR Website. 8 January 2015. Retrieved 11 January 2015.
  51. ↑ "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" (PDF). Pediatrics. 136 (5): 1008–1017. 2015. doi:10.1542/peds.2015-3108. ISSN 0031-4005. PMID 26504137.
  52. ↑ "State Health Officer's Report on E-Cigarettes: A Community Health Threat" (PDF). California Department of Public Health, California Tobacco Control Program. January 2015.
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