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:

Re: Fuming about e-cigarettes and harm

We fully agree with Kamerow, there does need to be far more research but also sensible regulations until we have some clear evidence from the research.(1)

It is of concern that e-cigarettes are gaining considerable positive coverage in the media both from manufacturers and also more recently from public health experts. We feel that the headline on Public Health England’s website “E-cigarettes around 95% less harmful than tobacco estimates landmark review” is not very helpful.(2) Some people may interpret this as advice that e-cigarettes are quite safe. However, there is a lack of evidence on the long-term health consequences of e-cigarettes.

The article that the review based its 95% figure on aimed to provide information on the relative harms of different nicotine delivery systems.(3) In order to do this a group of experts was convened to discuss and agree on the harmfulness of nicotine-containing products. But, the authors of the article quite rightly specify some important limitations and potential weakness of their research:
• “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria………..”
• “Another weakness might be the kind of sample of experts………”
Both of these are justified and indicate to us that great care is needed in formulating policy decisions on such evidence.

As the Government’s Chief Medical Officer previously noted in 2014, "We do not yet know the harm that e-cigarettes can cause to adults let alone to children….”(4) Although smoking tobacco by young people is still in a downward trend in England we would not wish to see e-cigarettes as an alternative lifestyle choice.(5) We have a real concern that e-cigarettes could become part of young peoples’ normative behaviour as they are perceived as ‘safe’.(6)

Further research should be undertaken to find out the long-term effects of e-cigarettes including in relation to the different flavorings used. In addition, regulation is needed so that the public can be assured about the quality and efficacy of these products.

1) Kamerow D. Fuming about e-cigarettes and harm. BMJ 2015;351:h4634

2) Public Health England. Press release. E-cigarettes around 95% less harmful than tobacco estimates landmark review. [viewed 22nd August 2015]. Available from:

3) Nutt D, Phillips L, Balfour D, Curran H, Dockrell M, Foulds J. et al. Estimating the harms of nicotine-containing products using the MCDA approach, European addiction research 2014: 20: 218-225.

4) Davies S. The Observer. 26th January 2014. [viewed 22nd August 2015]. Available from:

5) Health and Social Care Information Centre. Smoking, drinking and drug use among young people in England in 2014. [viewed 22nd August 2015]. Available from:,-drinkin...

6) Lloyd J. President’s Letter. International Journal of Health Promotion and Education. Vol 52, No 2, 116-117. 2014

Competing interests: No competing interests

28 August 2015
Michael Craig Watson
Associate Professor of Public Health.
Dr John Lloyd (Immediate Past President, Institute of Health Promotion and Education).
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA