E-cigarettes and the marketing push that surprised everyoneBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5780 (Published 26 September 2013) Cite this as: BMJ 2013;347:f5780
All rapid responses
In 1989, Michael Daube, who commented above, defined "creative epidemiology". I quote from
which itself is a very interesting read.
"Creative epidemiology is
something different . it is, and I quote directly
Michael Daube, who coined the term, defines
creative epidemiology as, ~the ability of
the good epidemiologist to rework data so
that what is essentially the same information
can be presented in a new and interesting
form. Thus creative epidemiology marries the
science of the researcher with the art and
creativity of the media advocate,..."
Cancer Institute 1989, Media Strategies for
Smoking Control . Bethesda : National Institutes of
of Health Publication No . 89-3013 .p . 21-22) .
I fear that ecigs are fast becoming the victim of "creative epidemiology".
Competing interests: former smoker, now ecig user
To see rhetoric of this nature is highly disconcerting. To suggest that there has not been a sizeable take up rate of e-cigs, is laughable. When some of the most influential investment houses are telling us that within a decade e-cigs will be outselling tobacco, there is something going on. What is missing in this outpouring of ignorance, is a basic understanding of smokers.
It is unlikely that e-cigs will ever 'test' well. The eternal quitter cannot quit and ecigs are not quitting which is why it appeals to smokers. When sterilised in an experimental situation they cease to function as intended. The fact that in these limited environments they have shown themselves to be at least as effective (or ineffective depending on your viewpoint) as current NRT is quite remarkable.
Across the world 'vapers' have been screaming their cause. Sadly, we are finding too many backs are turned; and the people who refuse to acknowledge our experiences are the very same ones stating, with absolute certainty, there is no evidence.
We are not fools, nicotine may well not be an inert and harmless substance, but then neither is the imbibation of alcohol or caffeine, the consumption of red or processed meat. Overindulging in sugar and fatty foods? Driving cars, riding bikes? Some of us probably don't even wash the pesticides from our vegetables! In short, we depart our beds every morning and venture into a world that is chock FULL of risk and danger.
We accept this. Very few of us will die peacefully in our sleep having lived a life untouched by risk. I accept that I was unlikely to ever give up smoking tobacco, so I chose something SAFER.
I despair that we having this bizarre battle. It’s disheartening to see the very people charged with protecting our health proclaim that we do not exist and that what has changed our lives must be taken from our hands!
Ironic, too, that the very people who say they are most concerned about controlling tobacco are blindly giving the current market to the tobacco companies through their inability to properly research the matter!
If, as it is so often stated, the end game is to reduce tobacco use across the world, then ecigs are a hand that you cannot afford to miss playing!
1. Electronic cigarettes for smoking cessation: a randomised controlled trial. (Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, Walker N.) Lancet. 2013 Sep 9. pii: S0140-6736(13)61842-5. doi: 10.1016/S0140-6736(13)61842-5. [Epub ahead of print]
Competing interests: No competing interests
Martin McKee seems taken aback by the response he has had from e-cigarette users about his article. Perhaps to many of them he appears a remote and unaccountable academic with easy access to influential publications in which he can declare opinions that bear no relation to their lived experience. Maybe they are concerned that McKee wishes to restrict or ban new technologies that they personally have found transformative to their health and welfare. It is easy to see why they may be agitated.
The tobacco control field has been marked by its lack of engagement with smokers. Understandable perhaps given that in the past the main consumer groups were pro-smoking. The war on the tobacco industry was also a war on smokers. Yet the legitimate concerns of public health advocates about the tobacco industry and its products had the unintended consequence of also marginalising and stigmatising smokers. Electronic cigarettes are the big game changer. And the rise in their use has been marked by the rise of a new social activism by e-cigarette users (‘vapers’). User Forums have been building alongside the growth in use of electronic cigarettes, but social activism took off across Europe from the beginning of this year. E-cigarette users are deathly scared about the Medicines and Health Care Products Regulatory Agency and European proposals in the Tobacco products Directive to regulate electronic cigarettes as medicines. They are also outraged that their views have not been considered by the MHRA, Department of Health and the European Commission.
The preamble of the WHO Constitution states that ‘Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people’ . WHO Director-General Dr Margaret Chan has referred to ‘the power of civil society and the activist community to generate the grassroots pressure that can ignite policy change’ . In most public health fields, community engagement is the norm: we welcome it, encourage it, and we learn from it. In AIDS, for example, engagement with affected populations has the highest priority – summed up in the slogan ‘nothing about us without us’. This slogan was borrowed from the field of disability and indicates the idea that policy should not be decided without the full and direct participation of people affected by that policy. Martin McKee is surprised by the response from electronic cigarette users. The strength of feeling aroused should be cause for reflection and engagement rather than as McKee puts it ‘academic analysis’.
Many public health experts and organisations in the tobacco control appear to have little understanding of the significance of the emergent population of e-cigarette users and their concern for protecting their health. We ignore public heath activists at our peril: Michel Sidibé Executive Director of UNAIDS has written of ‘the power of civil society to focus and generate transformational change’ . UNAIDS documents are replete with statements about ‘meaningful and respectful partnership work with civil society’. That doesn’t happen in the tobacco control field. Unfortunately, most tobacco control organisations are way behind the curve on e-cigarette consumers and have no strategy for engaging with these populations. Making light of e-cigarette users (Martin McKee has tweeted about ‘e-cig trolls’ ), patients, consumers and others affected by public health policies is counter-productive. Mary Robinson Former UN High Commissioner for Human Rights sums it up: ‘If only those with power ... would listen and incorporate the experience of those who have first hand knowledge of the reality of the situation on the ground – the results would transform the ideas of leadership and decision-making’.
1. World Health Organization, ‘Preamble’ Constitution of the World Health Organization: www.who.int/governance/eb/who_constitution_en.pdf
2. WHO (2008), ‘Launch of the Final Report of the Commission on Social Determinants of Health’ [statement to the press, Geneva, Switzerland, 28 August]: www.who.int/dg/speeches/2008/20080828/en/index.html
3. UNAIDS guidance for partnerships with civil society, including people living with HIV and key population, 2012. Joint United Nations Programme on HIV/AIDS (UNAIDS).
4. Twitter MartinMcKee@martinmckee 6 Sept 2013
5. M. Robinson (1996) ‘Empowerment Through Partnership’ [foreword] in B. Harbor, P. Morris and I. McCormac (eds) Learning to Disagree – Peace and Economic Development in Ireland Dublin: UNISON and IMPACT.
Competing interests: Competing interests: GS was member of the National Institute for Health and Care Excellence guidelines development group on tobacco harm reduction; his company Knowledge-Action-Change has received a smoking research feasibility grant from a company developing a nicotine product. DD runs community based Vapoutrails.tv which receives advertising from electronic cigarette companies.
In this important debate, one opinion is that if electronic cigarettes (EC) remain on the market, smoking of conventional cigarettes will increase. The other opinion is that the availability of a safer alternative will cause a decrease in smoking. This is in fact an empirical question. Provided EC are not regulated out of the market, we will have clear answers within a few years. If cigarette sales and/or smoking rates increase, sceptics would be proven right. If on the other hand cigarette sales and/or smoking prevalence go down, allowing EC to compete freely with cigarettes would turn out to be of benefit to public health. The problem is that if EC are regulated much more strictly than cigarettes now, the market monopoly of conventional cigarettes will be maintained and we will never learn what impact EC would have had.
The optimistic view has much stronger intuitive validity and it is also supported by a growing volume of evidence showing that EC are much better at providing an exit from smoking than entry into it. An alarming prospect is looming that on 8th October, European regulators, encouraged by ‘sceptics’, will destroy EC competitiveness against cigarettes by regulating them as medicines while allowing free sales of cigarettes to continue. If such a decision is made, the consequences for public health are likely to be seriously negative.
Competing interests: No competing interests
Stan Glantz and Rachel Grana suggest our trial is biased against patches, with their comment “…those randomized to e-cigarettes got them for free and had them mailed to their homes, while those randomized to the patch were mailed vouchers they had to pay a small fee to redeem at a pharmacy.” They describe 'usual care' in New Zealand correctly, but neglect to mention what else was stated in our paper: that we provided vouchers to participants in the patches group to cover the redemption costs, and therefore to address this purported source of bias.
1.Bullen C, Howe C, Laugesen M, McRobbie H et al . Electronic cigarettes for smoking cessation: a randomized controlled trial. Lancet September 7, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61842-5.
Competing interests: We declare that we have received no support from any companies for the submitted work and have no non-financial interests that might be relevant to the submitted work. ML, via his company Health New Zealand,previously did research funded by Ruyan (an e-cigarette manufacturer). CB and HM have undertaken research on Ruyan e-cigarettes funded by Health New Zealand, independently of Ruyan.
Well, how refreshing is that to read an article that totally gets e cigarettes and their users. I stopped smoking 6 months ago and now I use an e cigarette. I have reduced my nicotine from 24mg in stages to 12mg and I think I still have a way to go yet. I was never planning to give up smoking but I have and now I am comfortably reducing my nicotine. I don't care if I am never free of it altogether, it is orders of magnitude safer than smoking.
Competing interests: No competing interests
I have been overwhelmed by the response to my paper. Within a few hours of it being posted on the BMJ website I was attracting hundreds of messages on twitter, almost all personally abusive (“Vile cretin” was one of the kinder ones). I had no idea that the e-cigarette lobby was so well organised. Indeed, I was impressed with the speed by which this lobby created a web page on me, advising those posting tweets to moderate their comments as they were bringing the e-cigarette movement into disrepute (and suggesting that my paper was in some way an attempt to entrap them). The content of this mass of tweets justifies an academic analysis in its own right and I hope someone will undertake it.
For now I simply note that Clive Bates misrepresents me. I never said that e-cigarettes were a tobacco industry response to public health controls on smoking. Indeed, I noted explicitly that they were invented in 1963. What I did say is that the tobacco industry has, very recently, moved in to the market, taking over the small manufacturers, reformulating the product to look like real cigarettes, and marketing them on a vast scale. It is therefore no surprise that, as he notes, sales are booming.
Other responses have countered his arguments in detail, backed up by extensive evidence, and do not need repeating. However, I do feel it necessary to draw attention to one of his statements: “The normal controls on truth and fairness in advertising, supplemented by restrictions of the type applied to alcohol, should be sufficient to balance public health opportunities and fears that something might go wrong.” If he really believes that measures to address marketing by the alcohol industry have been effective, I leave others to judge the weight to place on his comments on e-cigarettes.
 The ANTZ pet rabble rouser. http://www.redheadfullofsteam.com/ (accessed 2 Oct 2013)
Competing interests: Author of original paper
As with all issues related to tobacco use, regulation and products, the real barometer of the potential impact of any initiative is tobacco industry response. In the case of e-cigarettes, the industry is scrambling to get on board.Lorillard's purchase of Blu ECigs in 2012 has been followed by Altria’s launch of MarkTen e-cigarettes and by Imperial Tobacco’s recent agreement to buy the e-cigarette manufacturer Dragonite International.
In July this year, British American Tobacco (BAT) launched its own brand Vype, which, if e-cigarettes are approved as a smoking cessation treatment in the UK, would ironically mean that the company could profit from public funding.
This shift may be indicative of industry recognition that a “Kodak moment” is imminent, i.e. the danger of being left behind by rapid technological innovation. The fear, and the more likely scenario however, is that BAT and competitor corporations intend to take advantage of marketing opportunities related to e-cigarettes. A recent Lancet Oncology editorial notes that e-cigarettes are not constrained by advertising and promotional restrictions on conventional cigarettes, and are “being marketed aggressively as lifestyle-choice consumables” through a range of media including high-profile sponsorship of Indy Car racing and UK football teams.
Such sponsorship strategies combined with product flavourings that include bubblegum, chocolate and popcorn, and broad use of social marketing make it hard to disagree with the editorial’s assertion that e-cigarettes are targeting young potential consumers. Nicotine is a highly addictive drug, however delivered, and adolescents who take up e-cigarettes run a very real risk of long-term addiction.
The related concern, as pointed out in other responses, is that e-cigarettes will renormalise smoking, thereby undermining decades of progress achieved by the tobacco control community to lower smoking rates thought a combination of legislation, tax increases and education. The greatest beneficiary of such an outcome will undoubtedly be the tobacco industry.
1. Robehmed N. E-cigarette Sales Surpass $1 Billion As Big Tobacco Moves In. Forbes 17 Sep. 2103 http://tiny.cc/mc5a4w.
2. Gustafsson K. Imperial Tobacco Agrees to Acquire Dragonite’s E-Cigarette Unit. Bloomberg 2 Sep 2013 http://tiny.cc/cd5a4w.
3. Manning S. British American Tobacco enters electronic cigarette market in Britain with the 'Vype'. Independent 29 Jul 2013 http://tiny.cc/sd5a4w.
4. Kodak moment. Economist 28 Sep 2013 http://tiny.cc/he5a4w.
5. Time for e-cigarette regulation.Lancet Oncology 2013;14(11):1027 http://tiny.cc/ju5a4w .
Competing interests: No competing interests
Martin McKee  rightly points out that the tobacco companies and the independent e-cigarette companies are marketing e-cigarettes with the same claims, tactics and media channels that effectively marketing cigarettes to youth that are now prohibited in the U.S. (e.g., flavors, celebrities, doctors, sports and festival sponsorship and TV commercials). E-cigarette marketing (including television commercials) encourages the use of the products anywhere, specifically in smokefree environments in an effort to re-establish positive social norms for nicotine addiction. These messages undermine existing smokefree laws and contribute to keeping people smoking cigarettes.
Far from replacing cigarettes with e-cigarettes, the most pattern of e-cigarette use is dual use with cigarettes. King et al. found that overall prevalence of ever use was 6.2%, but ever use among current smokers was 20% . Pearson et al also found ever e-cigarette use was most prevalent among smokers (11.4% ever tried compared to 3.4% overall) and almost all past-30 day use occurred among current smokers (4.1%, compared to 0.5% of former smokers and 0.3% of never smokers) .
Neither of the large, population-level studies to date demonstrate that smokers are successfully quitting by using e-cigarettes. In the longitudinal analysis of ITC Four-country survey data (U.S., U.K., Canada and Australia), despite 85% of users reporting that they were using the e-cigarette to help them quit smoking, there were no differences in quitting one year later between e-cigarette users and non-users . In a study of quitline callers, those who reported using e-cigarettes in a 7-month follow-up survey were significantly less likely to quit than those who hadn’t used e-cigarettes (21.7% among callers who used for one month or longer, 16.6% among those who used less than one month and 31.4% among never-users) . This is coupled with the results of the only randomized clinical trial to compare e-cigarettes to nicotine patch , where authors found no statistically significant differences between nicotine e-cigarette, non-nicotine e-cigarette and the nicotine patch. (This this study may have been biased against the nicotine patch in that those randomized to e-cigarettes got them for free and had them mailed to their homes, while those randomized to the patch were mailed vouchers they had to pay a small fee to redeem at a pharmacy.)
Dual use with cigarette smoking is also the dominant pattern among US middle school (61.1%) and high school (80.5%) students . We know from a Swedish cohort study of youth followed into late adolescence that dual use of cigarettes and snus predicted progression to current smoking by age 18 , suggesting that e-cigarettes could be a gateway to cigarettes.
Rachel Grana, PhD, MPH and Stanton Glantz, PhD
University of California San Francisco
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2. King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and Ever Use of Electronic Cigarettes Among US Adults, 2010–2011. Nicotine & Tobacco Research 2013:(online first).
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8. Galanti MR, Rosendahl I, Wickholm S. The development of tobacco use in adolescence among “snus starters” and “cigarette starters”: An analysis of the Swedish “BROMS” cohort. Nicotine & Tobacco Research 2008;10(2):315-23.
Competing interests: No competing interests
Marketing strategy on electronic cigarettes would be a real concern if it was oriented towards adoption of a new habit for the whole population. During past decades, tobacco cigarettes were marketed as a new, trendy habit for everyone to adopt. On the contrary, e-cigarettes are (and should be) marketed as alternatives to smoking. The target group is clearly defined. Marketing is essential to encourage smokers use e-cigarettes as a partial or complete substitute for smoking but needs to be regulated in order to prevent any attempts to promote their use in other population groups.
Using e-cigarettes together with tobacco cigarettes (so called “dual use”) is of value when smokers reduce cigarette consumption. Etter and Bullen surveyed 3,587 adult electronic cigarette users; more than 90% said that e-cigarettes helped them reduce cigarette consumption or quit smoking . In another survey by Dawkins et al., 71% of participants reported not smoking for several weeks while 55% of smokers reported “dramatic reduction” in cigarette consumption since using the e-cigarette . A worldwide survey of more than 19,000 e-cigarette users, performed by our group, found that 80% of participants quit smoking, while cigarette consumption went down from 20 to 7 cigarettes per day (median values) in those who continued to smoke (unpublished data). The selection bias in such surveys (it is expected that participants are mostly motivated and satisfied users) cannot discredit the fact that there is a substantial proportion of smokers who have quit or significantly reduced smoking by using the e-cigarette. This is further supported by the results of a randomized controlled study by Bullen et al. Although this study was biased against the e-cigarette (e-cigarettes are used as long-term substitutes to smoking, however there is no nicotine-containing e-cigarette available in New Zealand; concerning nicotine patches, the authors clearly state that in the manuscript that they provided vouchers to patch recipients to cover dispensing costs), it was found that e-cigarettes were superior to nicotine patch in smoking reduction and satisfaction to users . On the contrary, it is misleading to support that e-cigarettes are not successful by citing the study by Vickerman et al. . Obviously, that study examined quit rates in smokers who reported use of e-cigarettes at some time in the past, not during their quitting attempt. In fact, AllereWellbeing (the institute employing the authors and performing the study) released a statement mentioning that: “Many are misinterpreting it as saying that e-cigs did not help those who enrolled in QL services to quit. The analysis was never intended to answer that question.” . Besides efficacy as smoking substitutes, currently available evidence from chemical  and toxicology studies  supports that e-cigarettes are by far less harmful compared to smoking.
It is paradoxical to support that e-cigarettes may be a gateway to smoking just because there is dual use of electronic and tobacco cigarettes. Dual users are previously-smokers who, at some point, start using the e-cigarette. Three possibilities exist for these users: (a) they may quit smoking, (b) they may quit e-cigarette use but continue smoking, and (c) they may remain dual users. In none of these cases can e-cigarettes be considered gateway to smoking. There is no evidence supporting that people initiate nicotine intake by using e-cigarette and subsequently end-up smoking tobacco cigarettes .
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2. Dawkins L, Turner J, Roberts A, Soar K. 'Vaping' profiles and preferences: an online survey of electronic cigarette users. Addiction 2013;108:1115-1125.
3. Bullen C, Howe C, Laugesen M, McRobbie H et al . Electtonic cigarettes for smoking cessation: a randomized controlled trial. Lancet September 7, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61842-5
4. Vickerman KA, Carpenter KM, Altman T, Nash CM, Zbikowski SM. Use of Electronic Cigarettes Among State Tobacco Cessation Quitline Callers. Nicotine Tob Res 2013;15:1787-1791.
5. Alere Wellbeing Blog. E-Cigs: Are They A Problem Or A Solution? Posted by Ken Wassum May 22, 2013.
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7. Romagna G, Allifranchini E, Bocchietto E, Todeschi S, Esposito M, Farsalinos KE. Cytotoxicity evaluation of electronic cigarette vapor extract on cultured mammalian fibroblasts (ClearStream-LIFE): comparison with tobacco cigarette smoke extract. Inhal Toxicol 2013;25:354-361.
8. MHRA Commission on Human Medicines, Working Group on Nicotine Containing Products. Current use of electronic cigarettes. 2013, available at: http://www.mhra.gov.uk/home/groups/comms-ic/documents/websiteresources/
Competing interests: Dr Farsalinos has been the principle investigator in studies concerning e-cigarette safety for which the insitution (but not the researchers) has received funding from e-cigarette companies.