Nicotine without smoke—putting electronic cigarettes in contextBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1745 (Published 27 April 2016) Cite this as: BMJ 2016;353:i1745
All rapid responses
Recommending electronic cigarettes and liquids with variable specifications and quality for harm reduction
John Britton and colleagues wrote a comprehensive summary of potentially favourable and unfavourable aspects of e-cigarettes consumption (1). One potentially relevant aspect of nicotine exposure by inhalation was omitted: Unpublished, but communicated research by Robert F. Foronjy and colleagues on in vivo and in vitro models of e-cigarette exposure showed that e-cigarette aerosol, in a nicotine-dependent manner, caused emphysema in exposed mice. The researchers implicated nicotine as a causative factor in the pathogenesis of COPD (2). Although yet unconfirmed and limited to a mouse model, this piece of information may be worth considering in the further analysis of e-cigarette health effects.
One should be aware of the fact that to date no study has clearly shown that e-cigarettes are more effective for smoking cessation than available evidence based strategies using medication and counselling. Also, no study has clearly shown that switching completely from tobacco cigarettes to e-cigarettes leads to measurable health benefits within months or years. These studies may be difficult to conduct since dual consumption is common and complete long-term smoking cessation by using e-cigarettes is rare, maybe even an “orphan condition”, which may explain the lack of large scale long-term studies.
The process that led to the conclusion that the risk of e-cigarette use is 5% of that caused by tobacco smoking was highly debated following a critical editorial in the Lancet in August 2015 (3). Many of the experts involved in this favourable assessment of e-cigarettes for harm reduction were signatories of an earlier letter/statement to the director general of the WHO Margret Chan in May 2014 (4). It seems expert opinion was already then based on weak scientific evidence.
From a general perspective it is surprising, that non-standardised product (e-cigarettes) and non-standardised liquids containing nicotine are suggested as a harm reduction strategy in the article without mentioning the need for quality assurance and product standardisation. Britton et al point out that the devices are still evolving, underscoring the fact that a number of variables are changing or unknown…which may influence health effects of vaping. The time may be ripe for an e-cigarette with standardised specifications from an independent source, which may also facilitate research (5). Without defining the specifications of the recommended e-cigarettes and liquids, the rollout and recommendation of e-cigarettes for harm reduction purposes continues to be a large-scale human experiment with variable outcomes (6).
(1) Nicotine without smoke—putting electronic cigarettes in context. (2016) http://www.bmj.com/content/353/bmj.i1745
(2) Researchers working to define health risks of electronic cigarettes. (2015) http://www.chestdailynews.org/researchers-working-to-define-health-risks...
(3) E-cigarettes: Public Health England's evidence-based confusion (2015)
(4) Statement from specialists in nicotine science and public health policy (2014) https://nicotinepolicy.net/documents/letters/MargaretChan.pdf
(5) Eletronische Zigaretten nur noch vom Staat mit definierter Qualität? (2013)
(6) Electronic cigarettes: Ongoing human experiment without ethics approval (2015)
Macé M. Schuurmans, MD
Division of Pulmonology
University Hospital Zurich
Competing interests: No interests to declare. I am a member of the Working Group for Tobacco Prevention and Smoking Cessation of the Swiss Society of Pulmonology, and a member of the Federal Expert Commission of Tobacco Prevention.
Competing interests: No competing interests
We read with interest your article supporting the use of e-cigarettes  and wholeheartedly endorse any measure that reduces the public health harm from smoking. There has also been recent discussion regarding the appropriateness of requiring patients to stop smoking prior to elective surgery [2; BMJ weekly poll]. There is considerable evidence that smoking is associated with poor wound healing which is important in many types of surgical procedure irrespective of specialty [3-6] and smoking is contraindicated prior to some elective plastic surgery procedures. Whilst there are a multitude of harmful components of cigarette smoke, nicotine itself is known to affect wound healing via increased vasoconstriction . This has been supported by recent data showing a reduction in cutaneous blood flow following use of an e-cigarette .
We would therefore like to draw clinicians’ and patients’ attention to the fact that, whilst e-cigarette use may be a valuable aid in reducing harm from smoking in our patients, it is beneficial that they refrain from using all nicotine containing products prior to non-urgent operations. Many patients are unaware of the potential continued deleterious effects of nicotine replacement products and this should be explained carefully to them.
 Britton J., et. al. Nicotine without smoke—putting electronic cigarettes in context BMJ 2016;353:i1745
 Iacobucci G. Smokers and overweight patients are denied surgery, royal college finds 2016 BMJ 2016;353:i2335
 Akoz T, Akan M, Yildirim S. If you continue to smoke we may have a problem: smoking’s effect on plastic surgery. Aesthetic Plast Surg 2002;26:477e82.
 Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg 2001;108(4):1063e73.
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 Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg 2012;147(4):373-83.
 Rinker B. The Evils of Nicotine: An Evidence-Based Guide to Smoking and Plastic Surgery. Ann Plast Surg. 2013 May;70(5):599-605
 Page F., et. al. The acute effects of electronic cigarette smoking on the cutaneous circulation. J Plast Reconstr Aesthet Surg. 2016 Apr;69(4):575-7
Competing interests: No competing interests
The “Royal College of Physicians” recent report  expands on the 2007 report  by adding e-cigarettes into the arsenal of tobacco harm reduction. The report presents the view that e-cigarettes should be actively endorsed as smoking substitutes for smokers who can’t quit with other methods.
Neither the RCP report nor any tobacco harm reduction supporter (to the best of our knowledge) have ever supported that nicotine addiction is beneficial. However, we cannot deny the well-established scientific evidence that nicotine itself is not significantly (if at all) contributing to smoking-related disease. Recent literature reviews of the effects of nicotine on promoting cancer [3,4] failed to present any evidence from humans studies verifying laboratory findings. On the contrary, those reviews (and largely a significant part of the scientific community) have ignored extensive epidemiological evidence about the effects of nicotine on cancer and cardiovascular disease, derived from long-term studies of snus use. Snus users obtain similar or higher amounts of nicotine daily compared to smokers . However, its use, especially Scandinavian snus which is a cleaner form of smokeless tobacco, has minimal impact on cancer and cardiovascular disease incidence when compared to smoking [6,7]. Thus, the evidence clearly shows that nicotine is not the culprit for smoking-related morbidity and mortality, and there should be no room for “opinions” when evidence is clear. For this reason, major health organizations have accepted the long-term use of nicotine replacement therapies as substitutes to smoking [8,9].
The RCP clearly differentiated the addictiveness of nicotine from the health risks of smoking. The opposition to nicotine addiction is understandable and should be communicated to the society. However, simply criticizing nicotine addiction, while being an easy task, is of no help to smokers who are unable or unwilling to quit smoking with currently approved methods. We have a professional and ethical duty to clearly inform these people about alternative tobacco harm reduction products, including e-cigarettes. The “not safe” argument (in terms of absolutely safety), which is frequently used in tobacco control about e-cigarettes and smokeless tobacco products, has been characterized as poor quality health information  and has resulted in major misconceptions among healthcare professionals  and the public  about the risks of tobacco harm reduction products relative to smoking. It also violates a basic principle in toxicology, first described by Paracelsus in the 16th century, that everything can be toxic and the dose defines the toxicity .
The RCP rejects the use (or abuse) of the precautionary principle, which has been the main argument for the widespread criticism about e-cigarettes and tobacco harm reduction in general . The issues of e-cigarettes renormalizing smoking and attracting children are legitimate but unproven (until now) concerns. There is no evidence that youth are becoming regular e-cigarette users, become addicted to nicotine from e-cigarettes and subsequently switch to smoking tobacco cigarettes. The “gateway to smoking” effect is just a theory. At the same time we fail to even mention any potential benefits for youth, like the possibility for e-cigarettes to preventing smoking in those who would have otherwise smoked. The issue of e-cigarettes preventing smoking cessation is not only rejected by real-life experience but also by evidence. The European Union announced that, according to data from Eurobarometer 2014, 14% of e-cigarette users have managed to quit smoking with the use of e-cigarettes , which translates to 6.1 million fewer smokers. This is impressive considering the controversial information that the public receives about e-cigarettes, which is discouraging use. However, the 14% smoking cessation rate, although quite substantial, is misleading because it includes ever e-cigarettes users who have mainly experimented once or twice with e-cigarettes. It would be valuable to evaluate the effect among current and regular users, since experimentation is not expected to have any significant effect on smoking cessation and cannot induce any adverse health effects.
The RCP report provides appropriate and balanced information to smokers, without ignoring the fact that quitting smoking without using any alternative product is the best option. The concept and purpose of tobacco harm reduction is to care for smokers who are unable to quit without the use of an alternative, cleaner, nicotine source. Tobacco harm reduction is supplementing, not substituting, all other tobacco control efforts and strategies. This is exactly what the RCP report is presenting, and this is serving public health.
1. Tobacco Advisory Group of the Royal College of Physicians. Nicotine without smoke—tobacco harm reduction. Royal College of Physicians, 2016. Available at: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-toba... (accessed on April 29, 2016).
2. Tobacco Advisory Group of the Royal College of Physicians. Harm reduction in nicotine addiction: helping people who can't quit. Royal College of Physicians, 2007. Available at: https://cdn.shopify.com/s/files/1/0924/4392/files/harm-reduction-nicotin... (accessed on April 29, 2016).
3. Sanner T, Grimsrud TK. Nicotine: carcinogenicity and effects on response to cancer treatment – a review. Front Oncol (Cancer epidemiology and prevention) 2015;5:196.
4. Grando SA. Connections of nicotine to cancer. Nature Rev Cancer 2014;14:419-429.
5. Holm H, Jarvis MJ, Russell MAH, Feyerabend C. Nicotine intake and dependence in Swedish snuff takers. Psychopharmacology 1992;108:507-511.
6. Lee PN, Hamling J. Systematic review of the relation between smokeless tobacco and cancer in Europe and North America. BMC Med. 2009;7:36.
7. Hansson J, Galanti MR, Hergens MP, Fredlund P, Ahlbom A, Alfredsson L, Bellocco R, Eriksson M, Hallqvist J, Hedblad B, Jansson JH, Nilsson P, Pedersen N, Trolle Lagerros Y, Ostergren PO, Magnusson C. Use of snus and acute myocardial infarction: pooled analysis of eight prospective observational studies. Eur. J. Epidemiol. 2012, 27, 771-7799.
8. Medicines and Healthcare Products Regulatory Agency. Nicotine replacement therapy (NRT): New extended indication and consultation. 2010. Available at: http://www.mhra.gov.uk/Howweregulate/Medicines/Medicinesregulatorynews/C... (accessed on April 29, 2016).
9. Food and Drug Administration (FDA). Consumer Health Information. Nicotine Replacement Therapy Labels May Change. April 2013. Available at: http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM346012.pdf (accessed on April 29, 2016).
10. Kozlowski LT, Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tob. Control 2005;14(Suppl 2):ii3-7.
11. Lund I, Scheffels J. Perceptions of the relative harmfulness of snus among Norwegian general practitioners and their effect on the tendency to recommend snus in smoking cessation. Nicotine Tob. Res. 2012;14:169-175.
12. Kiviniemi MT, Kozlowski LT. Deficiencies in public understanding about tobacco harm reduction: results from a United States national survey. Harm Reduct. J. 2015;12:2.
13. Borzelleca JF. Paracelsus: herald of modern toxicology. Toxicol Sci. 2000;53:2-4.
14. Farsalinos KE, Le Houezec J. Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes). Risk Manag Healthc Policy. 2015;8:157-67.
15. European Commission. Eurobarometer 429. Attitudes of Europeans towards tobacco and electronic cigarettes. 2014. Available at: http://ec.europa.eu/public_opinion/archives/ebs/ebs_429_en.pdf (accessed on April 29, 2016).
Competing interests: KF: two (unpublished) studies were performed using unrestricted funds provided to the institution by e-cigarette companies in 2013. JLH: has received speaker honorarium and consultancy fees from Johnson & Johnson, Novartis, Pfizer, and Pierre Fabre.
We read with interest the recent RCP report on e-cigarettes (EC) and tobacco harm reduction . However, with regards to harm reduction, we felt an important point had been neglected. There is a real risk of explosion, fire and significant injury from EC and the re-chargeable lithium ion batteries that power them, a risk that was addressed to some degree in Public Health England’s 2015 report on EC . Clearly it is not only the nicotine delivery that requires regulation but also the production standards of the devices, their chargers and batteries.
We recently published the first case series of burn injuries as a direct result of EC devices . These unfortunate EC users described their devices bursting into flames like a "rocket in my pocket". These patients suffered significant burns to their thighs that required hospitalisation and surgical management. They used commonly available EC devices. They were not second hand, counterfeit or damaged devices, but devices ordered and purchased from shops now common place on our high-streets. These are not unique incidents. For example, two almost identical incidents were recently caught live on CCTV in both the USA and the UK [4,5]. Reports of injuries have rocketed in the last 6 months. A casual review of the internet media sources reveals an alarming epidemic of EC related fires and explosions, resulting in at least eight significant EC related burn injuries reported in the UK alone in 2016 .
This is a big problem with potential to cause serious harm or death . We would strongly recommend urgent consumer guidance on the safe charging and storage of EC devices and lithium ion batteries in order to reduce this risk. We would welcome the regulation that would come with MHRA licencing, which would undoubtedly drive significant improvements in operating guidance, as well as product quality and safety. It is completely unconscionable that public users are currently being sold devices with the potential to spontaneously explode and seriously injure. It would be completely unconscionable to prescribe such a device to a patient without a guarantee of safety. Given these devices are now being proposed for use by some of our young  and potentially most vulnerable  patients, these concerns need to be highlighted and considered as a matter of urgency.
 Nicotine without smoke: Tobacco harm reduction - A report by the Tobacco Advisory Group of the Royal College of Physicians. April 2016. Available online at: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-toba...
 McNeill A, B.L., Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update, A report commissioned by Public Health England. Public Health England, 2015.
 Nicoll K.J, Rose A.M, Khan M.A.A, Quaba O and Lowrie A.G. Thigh burns from exploding e-cigarette lithium ion batteries: First case series. Burns, April 2016. Article in press - DOI: http://dx.doi.org/10.1016/j.burns.2016.03.027
 Fox 5 KRBK. E-Cig Explodes in Man’s Pocket. Video available at: https://www.youtube.com/watch?v=lBDuKArHltc
 Williams A. Terrifying moment an e-cigarette explodes 'like a rocket' in a father's pocket just inches away from his seven-year-old son's face at a skating rink. MailOnline.
 Google Search: “e-cigarette explodes” https://www.google.co.uk/search?q=ecigarette+explodes&ie=utf-8&oe=utf-8&...
 BBC News. Man killed as e-cigarette 'explodes', Merseyside fire service says. http://www.bbc.co.uk/news/uk-england-merseyside-28701515
[8} Sutfin E et al. The Impact of Trying Electronic Cigarettes on Cigarette Smoking by College Students: A Prospective Analysis. American Journal of Public Health: August 2015, Vol. 105, No. 8: e83–e89.
 Borderud S.P, Li Y, Burkhalter J.E, Sheffer C.E, Ostroff J.S. Electronic cigarette use among patients with cancer: characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014 Nov 15;120(22):3527-35. doi: 10.1002/cncr.28811. Epub 2014 Sep 22.
Competing interests: No competing interests
Addiction is NOT treated by transposing patients to other, equally addictive, substances.
Addictive chemicals, by definition, inherently induce ever increasing dosing and abuse.
Deceased artist Prince is reported to have had an addiction to opiates. 
A doctor prescribing him oxycodone pills instead of morphine injections did not help his overall health.
A recent systematic review and meta-analysis has proved that e-cigarettes are associated with significantly less quitting among smokers. 
I wonder why addiction specialists from the Royal College of Physicians did not include this Lancet research study in their references.
Abrupt quitting works better than gradual reduction of cigarettes. 
Abrupt quitting smoking cessation is achieved by the second most common, and most effective non pharmacological treatment method used worldwide, clinical hypnotherapy. 
Even a single hypnotherapeutic session proved more effective than long term nicotine replacement therapy. 
Long term smoking abstinence after completed hypnosis therapeutic sessions is well documented.
Competing interests: No competing interests
Perfectly Predictable Predicts . . .
Considering the clearly stated Harm Reduction beliefs from the authors here, and indeed of the actual RCP document, many indeed being the authors of the previous Cochrane and PHE Reviews, this “Review” is no surprise at all. Analysis reveals challenges to their assumptions and presumptions, however:
The initial simplistic, potentially provocative and polarised presentation of “Us and Them” is misleading and erroneous. For example, the challenging personal perspective from two “expert” signatories to two previous opposing letters to Dr Chan at the WHO reveals that: opinions are not always so clearly divided: “Dueling Letters: which one would you sign? (1).
Moreover, recent “expert” opinion from Robert West, indeed one of the co-authors of the full RCP Report, highlights further incongruities to the primary postulation given by Britton et al and the RCP:
"If they were this game changer, if they were going to be – have this massive effect on everyone switching to e-cigarettes and stopping smoking we might have expected to see a bigger effect than we have seen so far which has actually been relatively small." (2)
It is indeed true that “Nicotine is most addictive when delivered to the brain quickly and in high doses”: “A cigarette is a scientifically designed drug delivery device that is intentionally engineered to deliver nicotine to the brain in seconds.” (3)
However, ENDS cannot do this . . . yet. This challenges and compromises for the majority of smokers a “full switch” away from tobacco, as confirmed in the dismal cessation rates, only comparable at best with NRT, seen in the few poor quality trials so far. If they do develop this ability, it would be reasonable to anticipate greater acceptability to smokers: however, also, greater uptake by youth, leading to further regular use, as opposed to the very high levels of experimental use we currently see. A double-edged sword indeed, with children being an integral “variable” of this “experiment” being run, real time on them.
“. . . nicotine causes little if any harm. . .”? The International Agency for Research on Cancer (4) has noted that “recent evidence has indicated the potential for nicotine to cause DNA damage”. Moreover, they continue: “In addition, exposure to nicotine has been shown to inhibit apoptosis, and stimulate cell proliferation and angiogenesis . . .”. Subsequently, they declare that an evaluation of electronic cigarettes and nicotine is a “High Priority”. Previous analysis further links nicotine to the pathogenesis of lung cancer (5). The RCP notes that lung cancer is a potential outcome from chronic use of electronic cigarettes.
“. . . many smokers who try nicotine replacement therapy revert to smoking.” This is clearly equally true for E-Cigarettes, as above. As Hartson-Boyce and Aveyard have recently stated (6), with intriguingly, the former being a co-author of the Cochrane Review of Electronic Cigarettes (7) and the latter being a co-author of this new RCP Report:
“Electronic cigarettes and other electronic nicotine delivery devices—These are currently not prescribable in most countries and have a very small evidence base. A Cochrane review showed
weak evidence that electronic cigarettes containing nicotine were more effective for helping people to quit smoking than those without nicotine.”
On what solid evidence are the RCP basing their opinion for electronic cigarettes to be currently recommended to smokers? Even the authors of previous key papers, co-authors of the RCP document, state that the current evidence base is “weak” (6) and of “low grade” quality (7).
McKee and Capewell’s previous commentary still stands the test of time: “Evidence about electronic cigarettes: a foundation built on rock or sand? (8)
Britton et al here state: “The report argues that e-cigarettes are unlikely to be harmless, and that long term use is likely to be associated with long term sequelae, including an increased risk of chronic obstructive pulmonary disease, lung cancer, possibly cardiovascular disease, and some other long term conditions associated with smoking.”
This is refreshingly honest, and contrary to what some “experts” have suggested, for example, e-cigarettes are: “. . . infinitely safer than a smoked cigarette” (9). Of paramount importance, furthermore, it is this statement from Britton et al that elucidates that the “Proof of Concept” originally postulated regarding e-cigarettes, as stated in the “Safety Report” of the Ruyan Electronic Cigarette, has been breached:
“Ruyan® e-cigarette is designed to be a safe alternative to smoking. The various test results confirm this is the case.” (10).
The repeated claim that: “. . . the magnitude of this risk is likely to be very small in relation to that from tobacco smoke, and the hazard to health arising from long term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco” still echoes the “expert opinion” formulated by a “selected” group of “experts” (11), with crucially a key characteristic of advocacy for “Harm Reduction”. Repeatability is central to science: could this be repeated with an alternate selection of “experts”, with no impassioned predisposition for this philosophy?
Toxicologists have recently challenged this unsubstantiated “scientific” assertion regarding safety (12). For the RCP now, and PHE previously, to assert that electronic cigarettes are a “low risk” product “. . . is, in the light of current knowledge, a reckless and irresponsible suggestion.” The authors continue regarding the assertion:
“It ignores the possibilities that users might be repeatedly exposed to hitherto undetected contaminants and by-products, as well as to carcinogenic chemicals, or their precursors (which have been detected in solvent extracts and vapours, and which are derived from tobacco during solvent extraction or generated during solvent heating), that can have effects at very low dose levels, following repeat exposures, which can occur without clear threshold doses, thus necessitating zero-dose extrapolation.”
The statement by Britton et al here regarding teen usage of e-cigarettes in the U.K. ignores the clear warnings with regard to the demographic characteristics of those substantial numbers of children that are experimenting. As Moore et al (13) point out:
“There was limited evidence of patterning in adolescent e-cigarette use by sociodemographic factors (with the exception of marginally greater use among boys in the primary school sample). This is in very stark contrast to consistent evidence of a strong sociodemographic patterning in tobacco use . . . “These data do suggest e-cigarette use could potentially spread throughout the youth population and become ‘normalised’, irrespective of socioeconomic status, ethnicity and gender, which was a feature of cannabis and ‘club drug’ use during the 1990s.” (My emphasis).
As argued above, as the devices become ever more efficient at delivering high doses of nicotine rapidly, endeavoring to mimic the currently superior delivery from cigarettes: the risk for regular use and addiction in children will increase.
As well as the weak evidence base currently for e-cigarettes to help smokers, it is the increasing risk to children that many scientists, academics and clinicians find unpalatable. However, this gamble with the health of children is a risk that apparently some are willing to propose as suitable:
“The British are saying, ‘Let’s see how we can help the main smokers today, who by the way are largely poor and less educated, and let’s not focus so much on kids, who may or may not be sickened by this 40 years down the line.’ ”
Not all British observers adhere to this position.
The one correct assertion made by Britton et al here is the divisive involvement of the Tobacco Industry, for they do openly state that their core business will remain in tobacco sales. Their products still target children. As has been stated:
"I think we have seen this movie before," Senator Richard Blumenthal said. "It is called big nicotine comes to children near you and you are using the same kinds of tactics and promotions and ads that were used by big tobacco and proved so effective" (14).
Competing interests: No competing interests
The recent analysis by Britton and colleagues advocating for e-cigarettes to be part of a comprehensive tobacco control strategy is alarming for a variety of reasons1.
First, the main assumed harm reduction potential for individual smokers switching to e cigarette is not supported by evidence2. In fact evidence increasingly suggests more dual smoking happening as a result, or a risk of transition to cigarettes3. But most importantly, the authors ignore the massive take up of e-cigarettes by youth who would otherwise not smoke or be exposed to nicotine. Their provided rational for such complacency is that UK data does not show substantial youth take up1. However, data from the US National Youth Tobacco Survey shows that current e cigarette us among high school students has increased between 2011-15 from 1.5% to 16.0% to become the most prevalent tobacco/nicotine product in this population4. That would be a great concern for any public health professional whether in the UK or US, because it undermines one of the main tenets of the harm reduction concept requiring that the “unintended consequences to the society be minimal”5. The assumption that a fashionable behavior in some countries will not travel with social media to other countries is wishful thinking at best, especially with the global nature of such an industry.
Similarly wishful, is the assumption that regulations will be able to deal with this issue by surgically marketing e-cigarettes to adult cigarette smokers but not youth nonsmokers1,5. In fact the behavior itself by adults will likely become an important means of promotion for youth no matter what regulations are out there.
Finally, the harm reduction model, where smokers quit/reduce smoking with e cigarettes but without substantial uptake by youth, is a suicide business model for the industry. Such a model means an ever shrinking market. This is why the industry will never abide by any harm reduction principle, while they certainly appreciate the free promotion of their products by members of the “health” community.
1- Britton J, et al,. Nicotine without smoke-putting electronic cigarettes in context. BMJ 2016:i1745.
2- Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med 2016;4(2):116-28.
3- Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control. 2016 Jan 25.
4- Singh T, Arrazola RA, Corey CG, Husten CG, Neff LJ, Homa DM, King BA. Tobacco Use Among Middle and High School Students - United States, 2011-2015. MMWR Morb Mortal Wkly Rep 2016;65(14):361-7.
5- Maziak W. Harm reduction at the crossroads: the case of e-cigarettes. Am J Prev Med 2014;47(4):505-7.
Competing interests: No competing interests