Intended for healthcare professionals


Evidence about electronic cigarettes: a foundation built on rock or sand?

BMJ 2015; 351 doi: (Published 15 September 2015) Cite this as: BMJ 2015;351:h4863

Protecting the health of people rather than scoring debate points should be our priority

Dear Editor

The responses to the piece by McKee and Capewell1 highlight the fact that the debate about the role of e-cigarettes in harm reduction and public health has become ideological although it is frequently disguised in the form of debate about the quality of evidence. In any ideological debate, no result will be achieved even if you have all the evidence you want, because people can always point at potential limitations in the evidence and retreat to their own camp. As public health professionals, scoring points in such a debate is not our prime duty, but is to protect people’s health. So I am going to assume here that financial interests has 0 effect on scientists’ position and scientific conduct, that e cigarettes have real potential in helping smokers quit and reduce their harm, and that the e-cigarette industry is built on a self-destructive business model aimed at helping all smokers quit but addicting no new customers, which will lead to their planned yet satisfactory demise.

I am still left with one very clear piece of data that has not received the required attention in this debate so far. Surveillance data from the US National Youth Tobacco Survey (NYTS) show that while cigarette smoking continues its decline among US youth, e-cigarettes has been dramatically increasing since 2011 to become the No. 1 tobacco/nicotine methods in this group (Figure 1)3. Interestingly, this was not associated with a rise in dual/multiple tobacco/nicotine use, the decline in cigarette smoking has been going down steadily before even e-cigarettes came to exist, and hookah smoking was also rising sharply during this period3.

There is only one explanation for this, is that many tobacco/nicotine naïve youth are taking up e-cigarettes (and hookah) and becoming addicted on nicotine through them. So unless one does not consider controlling the most powerful human organ, the brain, with one of the most powerful addictive substance, nicotine, is a problem to each individual’s health and the society at large, e-cigarettes is a big NO from public health perspective, despite all the goodwill of its proponents and industry.

1- McKee M, Capewell S. Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ 2015;351:h4863. doi:10.1136/bmj.h4863.
2- Maziak W. Harm reduction at the crossroads: the case of e-cigarettes.Am J Prev Med. 2014 Oct;47(4):505-7.
3- Arrazola RA, Singh T, Corey CG, Husten CG, Neff LJ, Apelberg BJ, Bunnell RE, Choiniere CJ, King BA, Cox S, McAfee T, Caraballo RS; Centers for Disease Control and Prevention (CDC).Tobacco use among middle and high school students - United States, 2011-2014. MMWR Morb Mortal Wkly Rep. 2015 Apr 17;64(14):381-5.

Competing interests: No competing interests

18 September 2015
Wasim Maziak
Professor & Chair, Department of Epidemiology
Florida International University
11200 SW 8th st. Miami, Florida 33199