Will Study Linking Vapes With Heart Failure Survive Scrutiny?

May 6, 2024

It’s been a busy few weeks for health scares around vaping, with media distortion of a cancer-adjacent study and an unjustified claim about seizures from the World Health Organization. New research suggesting that vaping could lead to heart failure has also triggered headlines in the United States and United Kingdom.

This research, unveiled by the American College of Cardiology (ACC) in April and presented at the ACC conference in Atlanta that month, found that “people who used e-cigarettes at any point were 19% more likely to develop heart failure compared with people who had never used e-cigarettes.”

“More and more studies are linking e-cigarettes to harmful effects and finding that it might not be as safe as previously thought,” stated the lead author, Dr. Yakubu Bene-Alhasan of MedStar Health in Baltimore.

The research involved over 175,000 subjects in the US—both vapers and non-vapers—with an average age of 52. In just under four years, 3,242 of the subjects developed heart failure.

According to the news release: “Breaking the data down by type of heart failure, the increased risk associated with e-cigarette use was statistically significant for heart failure with preserved ejection fraction (HFpEF)—in which the heart muscle becomes stiff and does not properly fill with blood between contractions.”

“However,” it continued, “this association was not significant for heart failure with reduced ejection fraction (HFrEF)—in which the heart muscle becomes weak and the left ventricle does not squeeze as hard as it should during contractions.”

In response to the study, Dr. James Leiper, senior research fellow at the British Heart Foundation, told media: “More research is needed to understand how exactly vaping increases the risk of heart failure, but these significant findings add to growing evidence that vaping has a harmful long-term impact on the heart and blood vessels.”

“The abstract raised many questions for me.”

The research has yet to be published in a peer-reviewed journal and should therefore be seen as preliminary. And some experts are highly skeptical of what’s been announced.

“The abstract raised many questions for me,” Dr. Gal Cohen, head of scientific affairs at the Rose Research Center in North Carolina, told Filter. He described finding a number of “red flags.”

The research team used survey and electronic health record data from the All of Us Research program, run by the National Institutes of Health, in order to analyze associations between vaping and new diagnoses of heart failure. 

But these data are so broad, Cohen said, that they provide very limited meaningful information—lumping in people who vape all day with those who have perhaps tried it just once.

“A population of ‘ever vapers’ was compared to ‘never vapers’ in the All of Us NIH database,” he explained.The All of Us database ‘ever use’ category includes ‘even 1 or 2 times,’ but does not capture any other information about duration of past use.”

Cohen added that the smoking history of the ‘ever vapers’ was not reported in the database—a striking absence, when “cigarette smoking is known to increase heart failure risk by two-fold or more.”

The authors of the new research say they’ve accounted for this, Cohen noted. However, “how the adjustment was done really requires complete transparency, not just presentation of the final adjusted odds ratio, given that [people’s potential smoking history] is so overwhelmingly large of a background effect.”

Complete transparency hasn’t been Dr. Cohen’s experience in attempting to engage with the research. He wanted to scrutinize the study and discuss how it’s being presented to people who smoke or vape. So he reached out to Dr. Bene-Alhasan, he said, requesting a copy of the materials presented at the ACC conference, as a way of starting a dialogue.

He also contacted Forbes, which had reported on the study, asking to discuss it; and Fox News, asking whether they had read the actual abstract rather than the ACC release.

“I got no response from any of them,” he said.

Cohen isn’t alone in pointing to potential issues with the research.

“It is noteworthy that only ‘ever use’ was found to be associated with the disease, while no association was found with intensity of e-cigarette use. It is biologically implausible.”

“The study is in reality a conference abstract which includes limited methodological information,” Konstantinos Farsalinos, a cardiologist and research fellow at the Onassis Cardiac Surgery Center in Athens, Greece, told Filter. “For example, it provides no information on the methods of diagnosing heart failure with preserved ejection fraction and—most importantly—on whether it was actively excluded at baseline, since the condition may preexist for a considerable time before the diagnosis.”

“As for e-cigarette use, it is noteworthy that only ‘ever use’ was found to be associated with the disease, while no association was found with intensity of e-cigarette use,” Dr. Farsalinos continued.

This and other factors, he said, “make a causal link between heart failure and e-cigarette use highly unlikely. It is biologically implausible that experimentation but not regular/frequent use could cause disease.”

Heart disease is the leading cause of death in the US, costing around 700,000 lives annually. In the UK, over 170,000 people die from heart and circulatory diseases each year, according to the British Heart Foundation.

The British Heart Foundation previously funded a study on the cardiological effects of vapes compared to cigarettes. Conducted by the University of Dundee, it found that within a month of making the switch from cigarettes to vapes, participants showed improvements in blood pressure, stiffness of the arteries, and other measures of blood vessel health.

The scientific argument around vapes and heart health has gone back and forth. A 2021 study published in the American Journal of Preventive Medicine, for example, found no association between vaping and increased risk of heart attack among people who’d never smoked—refuting three earlier studies that claimed such a link.

We don’t yet know the full details of the ACC study. But we do know that a climate exists of some scientists unjustifiably claiming health risks for vaping. In 2020, one high-profile study associating vaping with heart attacks was retracted.

In the ACC release, Dr. Bene-Alhasan said that “e-cigarettes are not recommended as a tool to quit smoking, since many people may continue vaping long after they quit smoking.”

But vapes are recommended as smoking cessation tools by numerous prestigious health authorities—and with good reason. The evidence is clear that they work for this purpose for many people, and that whatever harms they may or may not carry, they are far less harmful than cigarettes.



Photograph by Lindsay Fox via Flickr/Creative Commons 2.0

Kiran Sidhu

Kiran is a tobacco harm reduction fellow for Filter. She is a writer and journalist who has written for publications including the Guardian, the Telegraph, I Paper and the Times, among many others. Her book, I Can Hear the Cuckoo, was published by Gaia in 2023. She lives in Wales. Kiran's fellowship is supported by an independently administered tobacco harm reduction scholarship from Knowledge-Action-Change—an organization that has separately provided restricted grants and donations to Filter.

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