Electronic Cigarettes and Cardiovascular Risk: Caution Waiting for Evidence.

Introduction:
This article provides a summary of the regulatory approval of electronic cigarettes in various countries and the challenges associated with their legal regulation and on-market monitoring. It also discusses the potential impact of electronic cigarettes on the renormalization of smoking habits and their potential effects on cardiovascular health.

Key Points:

* The WHO recommends stopping the promotion of electronic cigarettes to non-smokers and young people, limiting advertising, and banning their use in areas where traditional smoking is already forbidden.
* The American College of Preventive Medicine's Prevention Practice Committee recommends screening electronic nicotine delivery systems in the general population, with special emphasis on initiation prevention among youth.
* In 2016, the US Food and Drug Administration (FDA) firmly regulated cigarettes, smokeless tobacco, and electronic cigarettes, including restricting sales to teens and free sample distribution. However, it allowed commercialization of flavors and did not impose restrictions on electronic cigarette advertisements.
* The FDA regulations bind manufacturers to submit an application to list the chemicals inside the devices and to prove that their products meet relevant safety standards.
* Many US states have banned the use of electronic cigarettes in areas where traditional smoking is already forbidden.
* The largest coordinated enforcement effort in the FDA's history resulted in warning letters and fines to retailers that illegally sold JUUL and other electronic cigarette brands to minors.
* The European Parliament approved a directive that limits the maximum amount of nicotine in electronic cigarettes.

Main Message:
The regulatory approval of electronic cigarettes varies by country and is constantly evolving to preserve public health interests. While electronic cigarettes may be a better option when compared with conventional tobacco products, their long-term and longitudinal impacts on cardiovascular health remain unclear. Additionally, there are substantial challenges involving the legal regulation and on-market monitoring of electronic cigarettes. It is important to balance the potential benefits of electronic cigarettes as a harm reduction tool with the need to protect young people and non-smokers from nicotine addiction and the potential renormalization of smoking habits.

D’Amario D, Migliaro S, Borovac JA, et al. Electronic Cigarettes and Cardiovascular Risk: Caution Waiting for Evidence. European cardiology. 2019;14(3):151-158. doi:10.15420/ecr.2019.16.2