Intended for healthcare professionals

Observations Yankee Doodling

Fuming about e-cigarettes and harm

BMJ 2015; 351 doi: (Published 26 August 2015) Cite this as: BMJ 2015;351:h4634
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
  1. dkamerow{at}

An English report is all for vaping while Americans still await promised regulation

Among the criticisms that public health officials have leveled at electronic cigarettes are that they are dangerous to health and that their flavors and easy availability are enticing and recruiting new smokers, especially young people. A new report from Public Health England, however, takes a surprisingly different view.1

The English study updated two previous reports on e-cigarettes and made headlines with a general judgment that e-cigarettes may not be so bad after all. Taking a strong harm reduction approach, the report concluded that e-cigarettes were about 95% safer than combustibles and thus could be “one of the key strategies to reduce smoking related disease and death.”1 It also advocated publicizing the 95% safer figure in light of “misinterpreted” previous studies of the harms of e-cigarettes. Since smoking in England, as in the United States, is increasingly concentrated among economically disadvantaged groups,1 the report found that e-cigarettes could provide a widely available low cost means to reduce smoking and improve health in these groups. This could help decrease population-wide health inequalities. The report also advocates incorporation of e-cigarettes into smoking cessation programs.2

Further, the report dismissed concerns about the use of e-cigarettes by young people, saying it was “rare” in England, with a prevalence of at least monthly use among otherwise never smoking young people of 0.3% or less. The report concluded that e-cigarettes “are attracting few people who have never smoked into regular use.”

Experimentation by young people

These opinions are not all widely shared in the UK and certainly contrast sharply with a much more negative stance on e-cigarettes taken by public health authorities in the United States. The Centers for Disease Control and Prevention’s director, Tom Frieden, for example, has crusaded against e-cigarettes for the harm they can cause both adults and young people.3 CDC surveys have focused on the striking growth in e-cigarette experimentation by young people, even though most of them will likely not become regular users of either e-cigarettes or combustibles. The proportion of high school students who said that they had used an e-cigarette in the previous month tripled from 2013 to 2014, from 4.5% to more than 13%.4 This was, however, accompanied by a decrease (from 12.7% to 9.2%) in use of traditional cigarettes, leading to a tantalizing question: is e-cigarette use in adults and adolescents a good thing (replacing tobacco cigarette use) or a bad thing (leading to cigarette use)?

Are e-cigarette manufacturers increasingly enticing impressionable adolescents to try their products with “cool” advertising, fruit flavors, and easy availability and use? US survey data would say unequivocally yes. But do e-cigarettes attract young people who would otherwise not smoke and get them hooked on nicotine, thus resulting in them becoming regular cigarette smokers? That’s much less clear.

Until recently, the only research published on this question has used cross sectional studies that are, by their nature, unable to establish causality.5 Theses studies have shown increases in e-cigarette use among young people and varying increases and decreases in use of cigarettes and other combustible tobacco products.

A longitudinal study of e-cigarette use among high school students has now been published, however, and it begins to answer the question of whether e-cigarettes lead to tobacco cigarette use.6 Surveying Los Angeles young teenagers between 2013 and 2014, the authors found that students who had used e-cigarettes at baseline were two to three times more likely to start using tobacco cigarettes in the next year than those who did not use e-cigarettes at baseline. The study was adjusted for many confounders but still does not provide definitive evidence of causality, for several reasons.

Firstly, it examined only smoking initiation rates and thus cannot address whether these students just experimented with various substances or actually became regular users of tobacco products. Secondly, the longitudinal effect found was bidirectional—that is, those who used tobacco products at baseline were also more likely to try e-cigarettes in the coming year. This only further muddies the waters in the controversy of what leads to what.

Banning sale to minors

That said, nobody thinks it a good idea for young people to use e-cigarettes. Young brains are very sensitive and easily addicted to nicotine, and there seems to be no reason to expose them to a product whose only proper use is to help adult smokers decrease or eliminate tobacco smoking. England, at least, is doing something about this, and in October a strict ban on e-cigarette sales to minors will begin to be enforced. The same cannot be said for the US.

We have been waiting since April 2014 for the Food and Drug Administration to issue its final national regulations on e-cigarettes. We are still waiting. At that time the FDA “deemed” authority over e-cigarettes and announced the intention to regulate them and their manufacture, including banning sales to people aged under 18 and from machines that young people can access. Most—but not all—US states have banned sales to minors, but there are still no national regulations. Also, no mention was made in 2014 of another regulation crucial to decreasing young people’s vaping: severely limiting the flavorings for e-cigarettes. Why can we have cherry crush e-cigarettes when cherry crush tobacco products are banned? And why is e-cigarette advertising not regulated when you cannot see tobacco product adverts anywhere on television?

The bottom line here, as always, is that we need more research—but also sensible regulations until that research proves conclusive.


Cite this as: BMJ 2015;351:h4634


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