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E-cigarettes and the marketing push that surprised everyone

BMJ 2013; 347 doi: (Published 26 September 2013) Cite this as: BMJ 2013;347:f5780

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Re: E-cigarettes and the marketing push that surprised everyone

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 [1]. 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 [2]. 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while cigarette consumption went down from 20 to 7 cigarettes per day (median values) in those who continued to smoke (unpublished data).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 [3]. On the contrary, it is misleading to support that e-cigarettes are not successful by citing the study by Vickerman et al. [4]. 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.” [5]. Besides efficacy as smoking substitutes, currently available evidence from chemical [6] and toxicology studies [7] 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 [8].


1. Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction 2011;106:2017-2028.

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

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.

6. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska-Czapla M, Rosik-Dulewska C, Havel C, Jacob P 3rd, Benowitz N. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2013 March 6, 2013 doi:10.1136/tobaccocontrol-2012-050859.

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:

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.

02 October 2013
Konstantinos E. Farsalinos
Researcher, Onassis Cardiac Surgery Center
Syggrou 356, Kallithea 17674, Greece