Intended for healthcare professionals

Rapid response to:

Observations Yankee Doodling

Fuming about e-cigarettes and harm

BMJ 2015; 351 doi: (Published 26 August 2015) Cite this as: BMJ 2015;351:h4634

Rapid Response:

Are E-Cigarettes a double edged sword? – Sleep walking down a smoky road

Dear Editor,

We read with interest your recent observation piece (1). The argument for and against e-cigarettes (EC) has been ongoing since they came on the market in 2004. We as Public Health professionals are a little concerned regarding the positive media coverage (2) given to EC on the publication of the independent review (3) commissioned by PHE. No one would refute that combustible cigarettes are extremely harmful, however, the message portrayed that e-cigarettes are almost harmless is worrying.

The independent review does not provide any evidence about the risk that widely available EC may encourage the subsequent uptake of combustible cigarettes, particularly in the young adult population. This concept is commonly known as gateway theory and is defined in the independent review as when “the use of one drug leads to the use of another drug”. In this case use of EC may lead to the use of combustible tobacco products and the authors of the review suggest that the terminology be abandoned as it does not have a large enough evidence base to be considered plausible. They further add that “Since EC were introduced to the market smoking prevalence among adults and youth has declined”.

However, the illuminating study (4) by Leventhal et al. referred to in the observation piece adds fuel to this “gateway theory”. They looked at how many 14year olds in 10 schools in California, USA who had never smoked, tried e-cigarettes and the relationship between this and their likelihood to use combustible tobacco products in the future. In the cohort of 2530 school pupils, 2350 had never smoked combustible cigarettes at the beginning of the study, but 8.7% of this group had used e-cigarettes. At 12 months follow up, teenagers who had tried e-cigarettes were 4.26 times more likely to go on to smoke combustible tobacco products than those that had not used e-cigarettes . A recent study (5) published in the Journal of Adolescent Medicine demonstrates that teenagers’ understanding about the risks and benefits of e-cigarettes is poor and their opinions are largely formed by the positive and glamorous advertising of EC that appears to be targeted at youth. Both of these studies were conducted in the US and should be a warning for us in the UK, that the possibility of non-smokers taking up e-cigarettes and then going on to smoke traditional cigarettes is a very real public health issue and should not be quickly dismissed for lack of data.

We very much welcome the approach taken in the UK that EC should be a medicinally regulated product (6). The devolved administrations appears to be taking different approaches to EC with Welsh Government planning to ban the use of EC in enclosed public places (7). This along with PHEs promotion of the importance of legislation that prevent s the sale of EC to minors (2) is encouraging, because clearly steps are being made to protect young people from taking up e-cigarettes.

In conclusion, the possibility that EC could increase the uptake of combustible tobacco especially in young people cannot be underestimated as shown by the recent study of US school children (4). Although causality cannot be inferred from observational studies the strength of association with an Odds Ratio of over 4 points to the fact that this needs careful consideration. The way in which we interact with and regulate the advertising of EC must be judiciously thought through, in order to minimise the risks of ensnaring our currently smoke-free teenage population with this widely available product containing nicotine, an addictive substance. Public health policy-makers need to adopt a wary approach in such a rapidly evolving field as EC and should always err on the side of caution.

1. Kamerow D. Fuming about e-cigarettes and harm. BMJ 2015;351:h4634
2. The Guardian (2015) Public Health England: vaping safer than smoking – video. Available at: (accessed on 25th August 2015)
3. McNeill, A., Brose, L. S., Calder, R. and Hitchman, S. C. (2015) E-cigarettes: an evidence update A report commissioned by Public Health England. Available at: (accessed on 25th August 2015)
4. Leventhal, A. M., Strong, D. R., Kirkpatrick, M. G., et al. (2015) Association of Electronic Cigarette Use With Initiation of Combustible Tobacco Product Smoking in Early Adolescence. JAMA, 314(7), 700-707.
5. Roditis, M. L and Halpern-Felsher, B. (2015) Adolescents' Perceptions of Risks and Benefits of Conventional Cigarettes, E-cigarettes, and Marijuana: A Qualitative Analysis. Journal of Adolescent Health, 57(2), 179-185.
6. MHRA. Licensing Procedure for Electronic Cigarettes and Other Nicotine Containing Products (NCPs) as Medicines. (accessed on 25th August 2015)
7. Welsh Government White Paper. Listening to you: Your health matters Consultation on proposals for a Public Health Bill (accessed on 25th August 2015).

Disclaimer: The views expressed above are solely those of the authors in their private capacity and do not in any way represent the views of Suffolk County Council.

Competing interests: No competing interests

27 August 2015
Eleanor J Delport
Foundation Year 2 Doctor in Public Health Medicine
Padmanabhan Badrinath
Suffolk County Council
Public Health Suffolk, Endeavour House, 8 Russell Road, Ipswich IP1 2BX