Intended for healthcare professionals

Rapid response to:

Head To Head

Should electronic cigarettes be as freely available as tobacco cigarettes? No

BMJ 2013; 346 doi: (Published 14 June 2013) Cite this as: BMJ 2013;346:f3840

Rapid Response:

Re: Should electronic cigarettes be as freely available as tobacco cigarettes? No

Who fears an alternative to tobacco smoking?

The pro and con’s side of the debate about electronic cigarettes could have analyzed the data on other alternative to tobacco smoking.(1,2) These are numerous and have existed for a long time. Eg. Swedish smokeless tobacco (snus), a moist powder tobacco product consumed by placing it under the upper lip for extended periods of time, similar to American dipping tobacco, which is not allowed elsewhere in Europe other than in Sweden. Snus must not be confused with snuff, a product made from pulverised tobacco leaves which is inhaled (snuffed) through the nose.

As the primary harms from smoking tobacco comes from the smoke (carcinogens, co-carcinogens, poisons, carbon monoxide) any alternatives to smoke are simple ways of reducing the deadliest epidemic ever seen. The World Health Organization (WHO) states that tobacco kills nearly 6 million people each year. Tobacco control looks like rearranging the deckchairs on the Titanic as WHO calmly expects an annual death toll of more than eight million by 2030.

Tobacco control’s failure is obvious in developing countries. In most rich counties, tobacco control is at most lazily implemented and the signature of the WHO Framework Convention on Tobacco Control is only a smoke screen as observed for warnings on cigarette packages.(3) Only Canada, the first jurisdiction to require full-colour graphic warnings on cigarette packages, and Australia which has just implemented plain packaging, are exceptions. However, it is Sweden that has the lowest prevalence of smoking among any nation because major shift has occurred from smoking to snus use.

Who can have legitimacy on the issue? Who can we trust: experts, clinicians or politicians? Tobacco control advocates are in a cul-de-sac and even enduringly failling to acknowledge the benefit of risk reduction policies. Thomas Frieden, Centers for Disease Control and Prevention director, underlined that despite 70% of smokers seeing doctors regularly, most try to quit smoking without professional help. Last, governments fear to lose their billions from the 80% charges rate on regular cigarettes and the European Union accepts violation of its founding principle, free trade, to ban snus! Sadly, Britain led the ban.(4)

The Journal must be congratulated for giving Etter the opportunity to pledge for common sense. Readers must be informed that Etter was one of the 10 members of the advisory committee on electronic cigarettes of the French Department of Health ( He was the only one to refuse to endorse its conclusions as, coincidentally, he was the only one to have published on the topic in journals indexed by PubMed.

The solution may come from the market. The tobacco companies, clever and fast runners, have entered the e-cigarette market long before policy makers woke up.(1,5)

1 Etter JF. Should electronic cigarettes be as freely available as tobacco? Yes. BMJ. 2013 Jun 14;346:f3845.

2 Chapman S. Should electronic cigarettes be as freely available as tobacco cigarettes? No. BMJ. 2013 Jun 14;346:f3840.

3 Braillon A, Dubois G. Warnings on tobacco packets. Is your MP concerned about public health? BMJ. 2011 Aug 2;343:d4883.

4 Raw M, McNeill A. Britain bans oral snuff. BMJ. 1990;300:65-6.

5 Bains M, Agombar H, Clarke E, Patel R. Time for NHS policy on electronic cigarettes. BMJ. 2012 Oct 17;345:e6587.

Competing interests: No competing interests

21 June 2013
Alain Braillon
Senior consultant, Alcohol unit
Northern hospital
80000 Amiens. France