Intended for healthcare professionals

Rapid response to:


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

Rapid Response:

Going backward: The renormalization of nicotine use

We agree with the published opinion by McKee and Capewell on the Public Health England’s (PHE) report [1]. The ongoing debate, however, seems to overlook e-cigarettes possible hazards by diverting the attention to potential benefit in terms of harm reduction among dual users, albeit arguable [2]. Therefore, it is essential to focus on its impact on naïve users; especially adolescents, which we intend to address here.

In the United States, e-cigarettes emergence permitted television and radio marketing of nicotine products once again, after the complete ban on tobacco products advertisement since the 1970s [3]. In 2014, around 18.3 million adolescents in the United States were exposed to at least one method of e-cigarette marketing method [4], which represents 68.9% of middle and high school students who participated in the 2014 National Youth Tobacco Survey (NYTS). More than one third of them (36.5%) were exposed to marketing messages via television. In the same survey, it was reported that e-cigarette is the leading tobacco product in use by American adolescents (lifetime and current use) [5]. In an online survey among 519 adult smokers and recent quitters, it was suggested that e-cigarette users were significantly more likely to have the urge to smoke conventional cigarettes compared to non-users after viewing e-cigarettes TV advertisement (83% and 72%, respectively) [6].

Moreover, a study among school children in Los Angeles revealed that non-smokers who used e-cigarettes were more likely to use combustible tobacco products in subsequent longitudinal follow up compared to non-users [7]. E-cigarettes supply the same addictive substance, i.e. nicotine, as in other tobacco products. Nicotine has been described as a gateway medication, not just for smoking other tobacco products, but also for alcohol and substance use [8 &9], which underscores a new paradigm of possible adverse outcomes that might be witnessed with the increasing e-cigarette use.

Furthermore, findings from a study in Utah suggest that state laws restricting sale to minors was inadequate to prevent the increasing prevalence of e-cigarette use among minors [10]. Noteworthy, the expanding use of e-cigarettes among adolescents is not confined to the USA as similar trends were observed in other countries (e.g. [11]), but data related to adolescents’ use, in general, are limited.

It can be concluded from the previous studies that e-cigarettes might lead to a rebound increase in other tobacco products use via two possible mechanisms. The first is a direct effect via the nicotine gateway mechanism [7-9]. The second, however, is an indirect one through its marketing messages [4-6], renormalization of smoking within public spaces, and societies [12]; while sale restriction alone might be ineffective in controlling adolescents’ e-cigarette increasing use [10& 13-14]. Therefore, we join the view to require regulating e-cigarette as a medication, if it has a role in smoking cessation [1&15]. This might be a reliable way to control naïve users’ (especially adolescents) access to e-cigarettes, until such reliable evidence on its safety is available.


[1] McKee M, Capewell S. (2015) Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ 2015;351:h4863
[2] Auf R. (2014) Electronic cigarettes and smoking cessation: a quandary? Lancet. Feb 1;383(9915):408. doi: 10.1016/S0140-6736(14)60144-6.
[3] History of Tobacco Regulation*.
[4] Centers for Disease Control and Prevention. (2015) Tobacco Use Among Middle and High School Students — United States, 2011–2014. MMWR, April 17, 2015 / 64(14);381-385
[5] Centers for Disease Control and Prevention. (2016) Vital Signs: Exposure to Electronic Cigarette Advertising Among Middle School and High School Students — United States, 2014. MMWR, January 8, 2016 / 64(52);1403-8.
[6] Kim AE, Lee YO, Shafer P, Nonnemaker J, Makarenko O. (2015). Adult smokers' receptivity to a television advert for electronic nicotine delivery systems. Tob Control. 2015 Mar; 24(2):132-5.
[7] Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB3, Sussman S, Riggs NR, Stone MD, Khoddam R, Samet JM, Audrain-McGovern J. (2015) Association of Electronic Cigarette UseWith Initiation of Combustible Tobacco Product Smoking in Early Adolescence. JAMA. Aug 18;314(7):700-7. doi: 10.1001/jama.2015.8950.
[8] Kandel DB. (1975) Stages in adolescent involvement in drug use. Science ;190:912-914
[9] Kandel ER, Kandel DB. (2014). Shattuck Lecture. molecular basis for nicotine as a gateway drug. N Engl J Med. 2014 Sep 4;371(10):932-43. doi: 10.1056/NEJMsa1405092.
[10] Utah Department of Health. Utah health status update: electronic cigarette use among Utah students (grades 8, 10, and 12) and adults. Updated December 2013.
[11] Lee S, Grana RA, Glantz SA. (2013) Electronic-cigarette use among Korean adolescents: a cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking. J Adolesc Health. doi: 10.1016/j. jadohealth.2013.11.003.
[12] Fairchild AL, Bayer R & Colgrove J. (2014). The renormalization of smoking? E-cigarettes and the tobacco "endgame". N Engl J Med. 2014 Jan 23;370(4):293-5. doi: 10.1056/NEJMp1313940. Epub 2013 Dec 18.
[13] Simons-Morton BG, Farhat T. (2010) Recent findings on peer group influences on adolescent smoking. The journal of primary prevention. Aug 1;31(4):191-208.
[14] Ahmad S, Billimek J. (2007) Limiting youth access to tobacco: Comparing the long-term health impacts of increasing cigarette excise taxes and raising the legal smoking age to 21 in the United States. Health Policy. 2007 Mar 31;80(3):378-91.
[15] Meikle J.( 2015) Vaping: e-cigarettes safer than smoking, says Public Health England. Guardian 2015 Aug 19.

Competing interests: No competing interests

16 January 2016
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